Reoperative Aesthetic & Reconstructive Plastic Surgery

1426
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This sequence shows management of early mastectomy skin ap necrosis as a result
of being unable to completely excise the skin between the old biopsy site and the
lateral border of the Wise pattern excision. In the middle frame one can appreci-
ate the ischemic necrosis of this thin bipedicle mastectomy skin ap. Management
was by early excision of the eschar (at 3 weeks) and advancement of the superior
mastectomy skin flap to the eventual areolar border. This allowed initiation of
chemotherapy without concern. Nipple-areola reconstruction was done 6 weeks
following the completion of chemotherapy.The nal photo shows the postopera-
tive result at 1 year.
ABDOMINAL FLAP NECROSIS
Following the harvest of the TRAM ap, occasionally necrosis of the random ab-
dominal skin ap can occur. This problem is most common in patients who have
had previous Kocher incisions in the right subcostal area. However, necrosis can
also develop in smokers, chronically obese patients, or patients in whom the amount
of tension on wound closure has been misjudged. In addition, wide undermining
above the costal margins and beyond the anterior axillary line divides the collateral
circulation to the superior abdominal ap and precipitate necrosis.
Management is similar to that described for mastectomy ap necrosis. Early suture
removal does not release enough tension to prevent partial-thickness or full-
thickness loss of the central part of the abdominal ap. Again, the best course of
action is conservative treatment until the eschar is clearly demarcated and begins to
separate spontaneously. Usually the underlying fascial repair is not affected and sim-
ply granulates over. Ultimately the wound will heal.

1427
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Clearly the key to avoiding this complication is prevention. A previous right sub-
costal incision is a “red ag” and demands extreme care to determine the correct
amount of abdominal skin undermining.
If the ap design can be shifted superiorly to include at least the lat-
eral portion of the subcostal incision in the ap outline, the area at risk
can be diminished.
Very limited undermining, if any, should be performed. Releasing only the left side
of the abdominal wall and only enough centrally to allow closure is preferred, even
if the result is at rst somewhat unaesthetic.
If the umbilicus has necrosed, little can be done early except to perform conserva-
tive debridement as necessary to allow healing by secondary intention. A delayed
umbilicoplasty can be performed at the time of nipple-areola reconstruction (see
p. 1470).
BREAST MOUND: PROBLEMS AND SOLUTIONS
LACK OF PROJECTION
Of the various free aps available for breast reconstruction, the TRAM ap is used
most often, yet it does not offer the natural projection of aps from either the thigh
or the buttock. The thickness of the abdomen’s subcutaneous fat is often inade-
quate to project the reconstructed breast to match the opposite breast. However, the
free TRAM ap is robust, and it permits plication sutures or ap molding to be
used at the initial operation to achieve reasonably good projection. If, however, pro-
jection is inadequate, several maneuvers can be performed secondarily.I usually per-
form these procedures at the time of nipple-areola reconstruction: 3 months fol-
lowing initial ap transfer or 1 month following the completion of chemotherapy.
Most patients undergoing autogenous reconstruction want to avoid breast implants
for improving projection if possible.Therefore, if the revision can be done with lo-
cal tissues alone, this approach is preferred.
VY advancement of the lateral portion of the reconstructed breast can decrease
lateral fullness and increase projection. With this technique, precise skin excision
and lateral fat plication improve both contour and projection.

1428
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
I mark the patient while she stands in front of me. Often the breast is too full lat-
erally, appears slightly ptotic, and lacks projection. By digitally pinching the skin
laterally, I can examine the contour of the inferior lateral portion of the breast on
both sides. In this way I can estimate the amount of skin that needs to be resected
to elevate the breast and reduce lateral fullness.
A triangle of TRAM skin flap or mastectomy
skin ap is marked for excision. If nipple-areola
reconstruction is to be performed concomi-
tantly, it is helpful to mark the estimated posi-
tion of the nipple-areola reconstruction on the
corrected breast mound while this correction is
simulated manually. The midline should also be
marked for placing pendulum sutures to help to
verify the nipple position intraoperatively.
Wedge
of tissue
removed
I usually perform these corrections with the patient under general anesthesia on an
outpatient basis, although local anesthesia is also an option. The patient is posi-
tioned with her arms abducted on arm boards at approximately 90 degrees. Care-
ful padding and positioning of the forearms are essential to prevent nerve injury (see
p. 1473).The patient will be sit up intraoperatively to con rm the accuracy of the
revision, so it is helpful to rehearse this maneuver with the anesthesiologist before
preparing and draping the patient for surgery.

1429
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Using a VY advancement technique, the incisions are reopened and the mastec-
tomy skin aps are undermined to the predetermined level. If the reconstructed
breast is too full laterally, the surface of the TRAM ap fat can be shaved down to
the right size. However, to use this additional tissue to increase projection, plication
sutures are placed to imbricate the lateral portion of the fat, forcing it to shift cen-
trally and thus further project the reconstructed breast mound.
The mastectomy skin aps can then be reapproximated over the TRAM skin island
temporarily as the amount of skin island to be trimmed is marked. The TRAM
skin island is then trimmed, and nal closure is carried out.

1430
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient received a delayed microvascular free TRAM ap reconstruction.Three
months postoperatively, the breast mound appeared too low and large, and it lacked
projection.
The correction was marked for a VY advancement of the lateral breast with plica-
tion sutures in the breast mound. The excess TRAM skin island was drawn be-
neath the lateral mastectomy aps, marked, and excised.

Comparing postoperative views following primary reconstruction and after revision
demonstrates a noticeable improvement in symmetry.
For larger discrepancies in volume as well as projection, an implant is the simplest
option if the patient will accept it. I prefer to use a small saline implant placed in
the subpectoral position. An excellent increase in projection can usually be achieved
using only a small 100 to 150 cc implant. Small implants can also ll areas of de -
ciency (for example, medial or lower lateral pole) or provide additional bulk in the
inferolateral portion of the reconstructed breast.
Large discrepancies in breast size in the presence of complete ap survival usually
indicate a planning error (for example, insuf cient donor tissue was available to
match the opposite side). However, if the patient concurrently underwent reduction
mammaplasty on the opposite breast, occasionally size discrepancy can result from
inadequate breast reduction. If this is the case, a revision of the reduced breast to de-
crease projection or bulk is the best way to gain symmetry (see Chapter 33).
1431
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Nipple-areola reconstruction was performed using the star ap technique.The are-
ola was tattooed 6 weeks later.

1432
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
UPPER POLE FULLNESS
Failure to adequately trim the TRAM ap during the initial operation will result in
a breast that is simply too large. This is the most common mistake that surgeons
make in their earliest experience with autogenous breast reconstruction. Occasion-
ally, however, the TRAM ap cannot be safely trimmed enough to match the op-
posite breast because of the risk to the blood supply of the random portions.This
situation commonly occurs in patients with an opposite breast that has a at upper
pole and only minimal ptosis. In addition, if the abdominal subcutaneous tissues
are thick, then it may not be possible to safely thin the upper portion of the TRAM
flap adequately. However, after 3 months the flap can be safely suctioned or
trimmed as long as the blood supply is preserved.
I attempt to preserve the main vascular pedicle to the free ap during revision. I
have had one case in which the ap became pale after secondary division of the
pedicle, even though I was quite con dent that the ap was receiving adequate
collateral circulation. Although the ap survived, I observed some atrophy that I
do not believe would have occurred if I hadn’t divided the pedicle (see pp. 1461
and 1462).

A bulky ap can be trimmed by clearing the excess surface bulk from the ap.This
excision is most commonly done in the superior pole, particularly if the breast
mound is also somewhat ptotic. The ap is reentered at the superior mastectomy
scar incision and the mastectomy ap is undermined to the subclavicular area.The
surface of this ap is trimmed to match the opposite side.
If necessary, the TRAM skin island can then be elevated beneath the superior mas-
tectomy ap, temporarily stapled, marked, trimmed, and resutured so that the full-
ness and ptosis are corrected simultaneously. If the breast is nonptotic but too full
superiorly or laterally, suction-assisted lipectomy is a simple and safe method of
secondary correction. In the absence of fat necrosis, the vascularized fat can be suc-
tioned, but care must be taken not to overreduce the breasts using this technique.
1433
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Rim of TRAM
skin island resected
Rim of TRAM
skin island resected

1434
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This 46-year-old patient underwent modi ed radical mastectomy and immediate
reconstruction of the left breast using a microvascular free TRAM ap. The ap
was too thick to be safely trimmed during the primary operation, so she was left
with a reconstruction that was too large and full superiorly. Liposuction was per-
formed on the left breast to make it symmetrical with the right breast. Nipple-
areola reconstruction was performed concomitantly. Although augmentation of
the right breast might have been an option in this patient, most patients prefer not
to alter the unoperated breast.Therefore we are now reconstructing smaller breasts
with autogenous tissue.

EXCESSIVE PTOSIS
If the breast is the proper size but too low, the easiest way to correct this without
lengthening the scars is to imbricate the lateral portion of the mastectomy aps.
This correction is best determined preoperatively while the patient stands. Very
slight overcorrection is recommended, because settling may cause ptosis to recur af-
ter 1 year.
1435
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
This patient underwent immediate free TRAM flap reconstruction of the left
breast. Although the reconstruction was symmetrical at the time of secondary re-
vision, gradual continued settling led to recurrent ptosis by 1 year postoperatively.
The other method of dealing with ptosis is to excise excess from the TRAM skin
island either at the superior mastectomy incision or in the inframammary fold if
the skin island was inset at that level. If the umbilicus was previously inset at the
6-o’clock position, resulting in a vertical scar in the median of the reconstructed
breast, both a horizontal and a vertical excision can sometimes increase projection
and decrease ptosis much like a conventional mastopexy.

1436
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient underwent bilateral simple mastectomy and immediate reconstruction
for premalignant mastopathy. Because of a previous appendectomy incision that di-
vided the deep inferior epigastric artery on the right, a pedicled TRAM ap was ro-
tated on the right and a microvascular free TRAM ap was transferred on the left.
Postoperatively, the patient requested correction of the at appearance and wide
base of the breasts. To correct the broad base, a V-shaped excision of skin was de-
signed in the midline of the inferior pole of each breast as with a conventional
mastopexy. Nipple reconstruction was carried out simultaneously followed by a
nipple-areola tattoo.

1437
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
The nal result is shown 11⁄2 years postoperatively.
INFRAMAMMARY FOLD IRREGULARITIES
Inframammary fold irregularities were more common before general surgeons be-
gan preserving the inframammary fold during the initial mastectomy.With the nat-
ural fold preserved, one can be assured that the lower pole will project symmetri-
cally from the proper position on the chest wall. However, when the fold has been
obliterated or needs to be reset (as with delayed reconstruction) irregularities can
occur. A common example is when one attempts to ll the reelevated inferior mas-
tectomy ap during delayed reconstruction rather than remove it.The lower mas-
tectomy ap will shrink after mastectomy alone, and there will not be enough ll
to allow projection or ptosis. In addition, the fold will not form at the proper level.
To prevent this problem, we usually debride the inferior mastectomy ap to within
approximately 1 cm of the projected inframammary fold so that the free ap can be
inset in the fold and project naturally.
If the inframammary fold is too low because of excessive debriding of the inferior
mastectomy ap or undermining, the fold must be secondarily elevated.This can be
done by reentering the inferior mastectomy incision and anchoring the inferior
mastectomy skin ap at a higher level. A rim excision of the reconstructed breast’s
inferior curve must accompany this maneuver to convert breast skin to abdominal
wall skin and thereby raise the fold level.
If the fold is indistinct, de nition can be improved using the percutaneous suture
technique coupled with suction-assisted lipectomy.The percutaneous sutures secure
the skin of the inferior mastectomy ap to the chest wall fascia, creating a discrete
inframammary fold.

1438
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
With the patient standing, the inframammary fold is marked at the proper level.The
area to be suctioned is also marked. During the operation, several small stab wounds
are made with a No. 15 blade in the new inframammary fold marks. Liposuction
with a small cannula can then be performed to remove fat and help to further de-
ne the fold.
A 2-0 Prolene suture on a large needle is passed through a stab wound and the
chest wall fascia, and it is brought out through the adjacent stab wound.The nee-
dle is then passed back through the stab wound it just exited, catching the dermis
of the mastectomy ap. The needle is then brought out through the original stab
wound, and the suture is tied down. The knot is dropped through the percuta-
neous stab wound, and a small suture is placed in the skin. A series of these sutures
can be placed adjacent to one another to greatly improve de nition of the infra-
mammary fold without reopening the entire fold.
Additional
suture sites
Additional
suture sites

The inframammary fold was slightly low in this patient. De nition was improved
using liposuction followed by placing percutaneous sutures.The corrugations dis-
appear with time, but the fold improvement persists.The area marked in the upper
pole was lled out with fat injection.
1439
Chapter 37
Reoperation Following Free Flap Breast Reconstruction

1440
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The result following immediate free TRAM flap reconstruction demonstrates
asymmetry in the medial part of the inframammary fold and slight ptosis of the
opposite breast.The patient desired a modest mastopexy in conjunction with cor-
recting the inframammary fold, nipple-areola reconstruction, and fat injections into
a subtle hollow of the infraclavicular region.
The inframammary fold was corrected using liposuction and the percutaneous su-
ture technique. A correction of the lateral contour was accomplished using VY ad-
vancement, and the nipple was reconstructed using a modi ed sh-tail ap.

The immediate postoperative result shows the improved contours of the breast
mound. Eight weeks later nipple-areola tattooing was performed.
If the inframammary fold is too high, it must be released and dropped down. Usu-
ally the flap can be mobilized slightly to drop into the new fold area; however,
sometimes inserting an implant will give more distinct contour.
SMALLER CONTOUR DEFECTS
1441
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
No matter what type of free ap is used, it is often dif cult to construct a breast
mound that has both satisfactory infraclavicular ll and ptosis. If ptosis is created, tis-
sue may be lacking in the infraclavicular hollow as well as in the tail of the breast
area. Small asymmetries in these areas are usually accepted by the patient. However,
larger depressions cannot be disguised in swimming suits or low-cut dresses, and pa-
tients may request secondary correction.To correct an infraclavicular depression, I
usually try to mobilize the free ap superiorly.

1442
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The mastectomy ap is elevated, and the superior pole of the reconstructed breast
is mobilized to the level of the muscular pedicle but usually not beyond. The free
ap can then be elevated superiorly and plicated to the pectoralis major muscle in
the infraclavicular fold with large permanent sutures.
To minimize tension on the plication, the mastectomy ap is sutured more inferi-
orly over the free ap skin island.

The TRAM skin island, not the mastectomy ap, is trimmed before
closure to create a lower scar and preserve normal breast skin.
This technique usually provides adequate ll as long as slight ptosis existed preop-
eratively. If there is no ptosis and superior mobilization of the ap would create
asymmetry inferiorly and inferolaterally, then an alternative method must be sought.
Sometimes the lateral portion of the ap can be mobilized and rotated into the tail
of the breast area. However, this method cannot correct more medial defects.
1443
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
This patient was referred for salvage breast reconstruction following simple bilateral
mastectomies and failed expander reconstruction. Mastectomies had been per-
formed because of a history of free silicone injection and premalignant mastopathy.
Bilateral free TRAM ap breast reconstruction was planned.

1444
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The postoperative result was satisfactory.
To correct severe contour deformities, a custom implant could be inserted, or a
second ap such as the latissimus dorsi could be transferred.
Three months after the ap transfer, a small de ciency in the tail of the recon-
structed right breast was evident. No ap excesses were available to rotate into this
area. Therefore a medially based fat ap was mobilized from the lateral portion of
the reconstructed breast mound and transposed into the de ciency in the tail of the
breast.

In the rst correction the breast was elevated slightly by excision along the scar, the
lateral aspect was contoured, and the nipple-areola was reconstructed. Postopera-
tively, she continued to complain of a small medial contour defect. Therefore in a
second revision a small fat graft was harvested from the axillary area and trans-
planted into the medial aspect of the breast.
1445
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Following immediate free TRAM reconstruction of the right breast, this patient
had a breast mound that was somewhat large and full laterally.

1446
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The fat graft became rm initially but
seems to hold up well over time. Fat
injection can also be used.
This patient provides a good example of the difference in the anticipated aesthetic
results achievable between immediate reconstruction and delayed reconstruction.
The patient had had a previous modi ed radical mastectomy on the right side, but
new cancer subsequently developed in the left breast. She desired bilateral breast re-
construction, which was performed using bilateral free TRAM aps. Following the
initial reconstructive procedure, symmetry was close in terms of volume, but there
was an obvious difference in the skin color and texture between the two sides.The
high right mastectomy scar will always limit the type and style of clothing that she
can wear.

1447
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
During revision the monitoring skin island, which had remained exposed on the
left breast, was excised.The superior mastectomy ap was rotated inferiorly, closing
the monitoring skin island area much like a diaphragm.
Following tattooing, the TRAM skin island is no longer visible on the left but is
readily apparent on the right breast.The skin island itself was elevated as a sh-tail
ap and fashioned into a nipple.

1448
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This 40-year-old female developed breast cancer during pregnancy and required a
left modi ed radical mastectomy and postoperative radiotherapy.
We waited nearly 1 year following completion of her radiotherapy to perform re-
construction. Because of a signi cant family history a preventive mastectomy was
performed on the right side. As in the previous case, a marked difference can be
seen in the initial result between the immediate reconstruction side and the delayed
side. Revisions were performed by liposuction alone.
The result is shown 1 year postoperatively.

This 50-year-old runner strongly de-
sired an autogenous reconstruction.
She was a good candidate because of
the radiation injury to the right chest
wall.
1449
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Although ap volume was minimal, we were able to establish
satisfactory resurfacing of the right chest wall. Secondary revi-
sions at 3 months included placing silicone gel implants and
tailoring the axillary mastectomy skin ap. Final stage nipple-
areola reconstruction was delayed until the mounds were sym-
metric.
The nal postoperative result is shown
at 2 years.

1450
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
SCARS
During secondary surgery I routinely try to improve any scar on the breast that I
think will respond to usual scar revision techniques.When asked, patients will point
out which scars are most dif cult to conceal with clothing. With delayed recon-
struction, a transverse scar usually extends across the middle or upper portion of the
breast.
If the mastectomy ap can be brought lower during mound revision,
the scar will be easier to hide beneath clothing.
With skin-sparing mastectomies we often leave a monitoring skin island at the fu-
ture site of the nipple-areola complex.The intent is to completely excise the mon-
itoring skin island during nipple-areola reconstruction. However, complete excision
is not always possible, and occasionally a segment of the periareolar scar must be left
in a visible position. Although these scars fade with time, it is always preferable to
complete the reconstruction with only native breast skin covering a completely
buried free ap.
This 45-year-old patient underwent a modi ed radical mastectomy for intraductal
carcinoma of the left breast.

Immediate reconstruction was performed using a free TRAM ap. Postoperatively
the left breast was slightly higher than the right breast.The patient desired a mod-
est mastopexy of the right breast for symmetry. Periareolar mastopexy of the right
breast, mound correction of the left breast using liposuction, and nipple-areola re-
construction were performed.
1451
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
The postoperative result before nipple-areola tattooing demonstrates good scar po-
sitions, which will allow the patient to wear a variety of clothing styles.

1452
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This patient illustrates a failed tissue expander reconstruction. In the preoperative
photo she has an intact right tissue expander, but the left side has extruded.The sur-
geon attempted to place a latissimus dorsi musculocutaneous ap, but it also failed.
We elected to use bilateral muscle-sparing free TRAM aps to salvage the left breast
and replace the expander on the right. Secondary reconstruction included scar re-
visions and nipple-areola reconstruction.The result is shown 1 year postoperatively.
NIPPLE-AREOLA RECONSTRUCTION
I prefer to delay nipple-areola reconstruction until all revisions of the breast mound
have been completed, and the patient and I are satis ed with the symmetry. If a ma-
jor mound revision is required, I sometimes perform nipple-areola reconstruction
as a separate procedure to allow settling and softening of the breast mound. How-
ever, nipple-areola reconstruction can usually be performed at the same time as
mound revision.

Even when the mound is revised during the same operation, the position of the re-
constructed nipple may be determined by manually holding the breast mound in
its corrected position.The patient is viewed from the front, and the nipple position
is marked where it will look best on the reconstructed breast mound and in rela-
tion to the opposite nipple-areola complex.The day before surgery I also ask the pa-
tient to place a small circular adhesive bandage where she believes the nipple-areola
would look best.
1453
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
During the operation, one 2-0 silk suture can be placed at the manubrium, and a
second suture can be placed at the xiphoid in the midline. After mound revision,
the nipple positions can be placed symmetrically by using these two sutures like a
pendulum with the patient sitting.

1454
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
If the opposite nipple is large or broad, my procedure of choice is a nipple-sharing
composite graft, if the patient concurs. Otherwise my preferred technique is a star
ap,46 a modi cation of the sh-tail ap,47 or the Hammond technique.The mod-
i ed shtail ap uses two small skin–fat aps from the breast mound and allows
primary closure of the donor sites without skin grafts.
2.5 cm
1 to
1.5 cm
A
C
B
The modi ed sh-tail ap is designed as shown, although the angle between the
two aps and their orientation can vary.The design of these aps occasionally must
be altered depending on the periareolar scars. However, they can be oriented in
virtually any direction by simply designing the aps where skin and fat are most
available.
The wings of the ap are elevated from the apex toward the central pedicle. As the
edge of the proposed nipple is reached, the dissection is deepened into the subcu-
taneous fat without further undermining beneath the center of the nipple.The su-
perior aspect of the nipple is left intact.The inferior portion is incised and the two
aps are tilted up.
FPO
A
C
B

Flap A is rotated around the base. Flap B is folded over to form the top of the nip-
ple.The tip of ap B can be deepithelialized and tucked into the central part of the
nipple to increase bulk. The donor sites can be closed primarily. The apex of ap
C, which slides underneath the nipple, is deepithelialized to serve as a supporting
platform and to prevent retrusion of the reconstructed nipple.
1455
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Nipple-areola tattooing is usually delayed 6 weeks to allow the tissues to stabilize.
Alternatively, tattooing can be performed rst, followed by ap elevation and nip-
ple-areola reconstruction.48
A
B
C
B

1456
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In this patient the aps were oriented vertically, because it seemed this position
would result in less constriction of the breast cone. The aps were dissected, ele-
vated, and transposed.The postoperative result is shown 1 month following tattoo-
ing of the areola.
As we have gained more experience with permanent pigmentation techniques, I
have come to prefer to create the illusion of an areola by tattooing as opposed to
skin grafting. The native skin of the breast or the ap accepts the pigments much
more readily than a skin graft, and therefore the color appears more stable over the
long term.

This 40-year-old woman presented with a small in ltrating ductal carcinoma of
the right breast. Reconstruction was performed using a free TRAM ap. Following
the initial procedure the breast was slightly full in the lateral axillary area. Small
corrections in this area and in the anks were made using liposuction. Nipple re-
construction further reduced the size of the monitoring skin island. Postoperative
tattooing completed the reconstruction, resulting in a completely buried ap and
a good symmetrical match.
1457
Chapter 37
Reoperation Following Free Flap Breast Reconstruction

1458
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
This 40-year-old presented with carcinoma of the right breast and a positive fam-
ily history. Bilateral mastectomies and immediate TRAM reconstruction were per-
formed.
Twelve days postoperatively the patient avulsed the right pedicle of her free ap. She
presented with a large hematoma around the right reconstructed breast. Explo-
ration was delayed for 24 hours, because the ap appeared viable. Ultimately the
disrupted pedicle was discovered and vein grafted. Nevertheless the patient devel-
oped moderate atrophy on the right reconstructed breast.

The patient preferred to undergo liposuction-reduction of the left breast to match
the smaller right side. A skin-only vertical mastopexy was also planned as well as
nipple-areola reconstruction.
1459
Chapter 37
Reoperation Following Free Flap Breast Reconstruction

1460
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Nipple-areola reconstruction using modi ed sh-tail aps is demonstrated.
The nal result is shown at 2 years postoperatively.This is a fascinating case because
it demonstrates that relatively rapid ingrowth of peripheral circulation occurs in
some patients. Although the ap was revascularized, I believe that it would have sur-
vived at 12 days, even without restoring the pedicle.

REVISIONS OF THE RECONSTRUCTED
NIPPLE-AREOLA COMPLEX
1461
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Complete loss of a reconstructed nipple is unusual, but composite grafts are partic-
ularly at risk for this complication.This patient suffered complete loss of a compos-
ite graft, which I believe was caused by the ap pedicle being divided when the
breast mound, which was created with a free TRAM ap, was revised.The ap im-
mediately became pale but appeared to have bleeding at the skin edges.We elected
to proceed with nipple reconstruction using a composite graft. However, dermal
bleeding was minimal when the recipient site was deepithelialized. Although the
breast ap survived, the nipple reconstruction was lost.

1462
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Secondary reconstruction using a skate ap was required.
Minor revisions of a reconstructed nipple are occasionally indicated, such as when
a reconstructed nipple heals with a small overhang of tissue or is tilted to one side.
These problems are usually corrected easily on an outpatient basis at the time of tat-
tooing. Some patients experience more atrophy of a reconstructed nipple than is
desirable and request secondary correction. I have improved several such nipples by
performing a second star ap reconstruction designed to include the original atro-
phied nipple. Another method of correction is to transfer a composite graft from
the opposite nipple as an “on top–plasty.” The previous inadequate nipple is bi-
valved, and the composite graft is sutured into position on top.
Tattooed areolar pigmentation always fades, although it usually stabilizes 6 months
to 1 year following initial application. Touch-ups are sometimes requested by the
patient or suggested by our of ce nurse who does most of these nishing touches.
If the nurse believes the color can be improved, this procedure is easily accom-
plished in the of ce. If the tattoo is too dark, lightening is more problematic:either
a lighter color needs to be added on top of the darker pigment,or a partial-thickness
excision or dermabrasion must be performed to lighten the area before tattooing
it again.

COMPLEX RECONSTRUCTION
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Reoperation Following Free Flap Breast Reconstruction
This 55-year-old patient was referred following a left modi ed radical mastectomy
and right simple mastectomy with two failed expander reconstructions and a left
failed latissimus dorsi ap. A small latissimus skin island remained. Because of the
scant tissue available in the lower abdomen, we elected to use both halves of the
TRAM to restore the left breast.
The latissimus dorsi was deepithelialized and left buried to give a small amount of
additional bulk. The free ap was transferred based on the left internal mammary
artery and vein.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The second stage revision required autologous fat injection into the infraclavicular
hollow, nipple-areola reconstruction, and right augmentation-mastopexy.
The nal result is shown at 2 years.

DONOR SITE PROBLEMS
Some of the problems affecting donor sites for free ap breast reconstruction are
discussed in Chapter 6. Speci c problems that may need to be addressed at the time
of revision for breast reconstruction are presented here.
TRAM FLAP
Abdominal deformities following free TRAM ap transfer fall into the following
categories:(1) hernia, (2) contour irregularities, (3) umbilical malposition or necro-
sis, and (4) scarring.
Hernia
To date, the incidence of hernia formation following free TRAM ap transfer is not
dramatically less than that following conventional TRAM reconstructions.The rea-
son is that both techniques violate the fascia in the most susceptible region of the
abdominal wall:the interior rectus sheath at the level of the arcuate line and below.
The internal oblique muscle and fascia play an important role in maintaining ab-
dominal wall integrity, and they must be carefully resutured following the harvest
of the TRAM ap. Without innervated muscular support the fascia can attenuate,
resulting in the characteristic bulge between the umbilicus and the pubis at the site
of the muscle harvest.This hernia may be entirely asymptomatic except for a con-
tour deformity, or a patient may complain of general discomfort or a sharp pain in
this area. A distinct fascial ring is usually not palpable.The patient may or may not
request surgical correction. I have never seen an intestinal incarceration or other
surgical emergency precipitated by this type of hernia.
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Chapter 37
Reoperation Following Free Flap Breast Reconstruction
A bulge of this type can be corrected by reelevating, advancing, and reclosing the
abdominal skin ap on the symptomatic side. Depending on the size and location
of the defect, the umbilicus usually does not need to be released. In most cases it is
not necessary to enter the abdominal cavity.

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The external oblique fascia and internal oblique muscle are located laterally by pal-
pation, and the scarred edge is trimmed. Immediately and inferiorly, the linea alba
and fascia above the pubis are incised sharply.
If the internal oblique and external oblique aponeuroses can be advanced medially
and inferiorly for primary repair, this correction is preferred.
For strong, long-term support, special care must be taken to achieve
secure and accurate closure of the internal oblique aponeurosis.
It is often not possible to primarily close the defect in larger hernias. Therefore a
sheet of polypropylene mesh must be inserted.The mesh is stretched taut to main-
tain long-term support, and it is sutured circumferentially inside the fascial rim us-
ing mattress sutures. Drains are placed and the wounds are closed.
Fibers of
external oblique
aponeurosis
Old transverse scar
Linea alba
Fibers of
internal oblique
aponeurosis
External oblique
aponeurosis
retracted
Internal oblique
aponeurosis
incised
Internal oblique
aponeurosis
sutured to
midline at
linea alba
Extent of
external
oblique
aponeurosis
External oblique
aponeurosis
suture across
midline

This 50-year-old patient underwent delayed reconstruction of the left breast using
a contralateral microvascular free TRAM flap. Four months postoperatively, she
noted a sudden onset of pain in the right inferior portion of the hypogastrium as-
sociated with the appearance of a visible bulge.
1467
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Exploration of the bulge revealed that the internal oblique and external oblique
muscles had retracted well beyond the semilunar line. It was not possible to read-
vance these muscles;therefore a sheet of Marlex mesh was used to close the defect.
Long-term correction has been maintained.

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Contour Irregularities
Removing an ellipse of skin and fat from the lower abdomen, coupled with tight-
ening the epigastrium, results in bulging of ank fat and a change in waistline di-
mensions. Abdominal closure can accentuate the bulge.This deformity can be ag-
gravating to some patients, particularly those who had excess fat in that area
preoperatively.These contour irregularities may be corrected at the time of nipple-
areola reconstruction.
The areas of excess fat are marked while the patient is standing.These sites usually
include the ank and occasionally a thick epigastric area as well. A small dog-ear
correction in the ank is often carried out, and liposuction of this area is performed
through the incision. I prefer to use the syringe liposculpture technique for con-
touring.These regions may also be accessed through small stab wounds in the pre-
vious lateral abdominal scar.
Umbilical Malposition and Necrosis
If the umbilicus is not brought back to the midline before fascial closure following
the harvest of one or both rectus abdominis muscles, it will heal off-center.This de-
fect, which patients often nd disturbing, can be dif cult to correct. Occasionally
slight malposition results from disruption of the tacking sutures placed between
the dermis of the umbilical stalk and the rectus sheath. If this appears to be the
cause of the deformity, a small incision is made at the border of the umbilicus, the
dissection is carried down to the rectus sheath, and plication sutures are placed to
draw the umbilicus into the midline. Only a small correction is possible using this
local approach.

If the malposition is signi cantly off-center, as it was in this patient, a more in-
volved surgical repair is necessary.
The abdominal incision is reopened, the lower abdominal skin ap is reelevated,
and the umbilical stalk is transected.The abdominal fascial defect is oversewn and
the stalk is then drawn back into the midline and sutured with a heavy Prolene
permanent suture. Drains are placed and the wound is reclosed.
Umbilical necrosis is an unfortunate complication that results from either a critical
disruption of the circulation to the umbilicus or suturing the umbilicus under ex-
cess tension. Both result in death of the umbilical stalk, slough, and healing by sec-
ondary intention. A super cial depression and discolored scar occur but with none
of the aesthetic features of the native umbilicus. Also, if the abdominal skin de-
hisces from the umbilical stalk, overhealing will result—the umbilical stalk may still
be alive but underneath the abdominal skin. Cyst formation or local infection may
ensue. Neoumbilicoplasty is recommended for both of these situations.
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Chapter 37
Reoperation Following Free Flap Breast Reconstruction

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PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The umbilical position is determined and marked—usually at the location of the
umbilical necrosis.The technique of Illouz49 gives the best results.
Two semicircular aps are incised and thinned. Small superior and inferior triangu-
lar aps are also developed. The dissection is carried down to the anterior rectus
sheath. Ideally the umbilical stalk is located and resutured to the abdominal skin
aps.
If the umbilical stalk is completely necrosed, then the skin aps are sutured with
permanent sutures to the linea alba or anterior rectus sheath. A skin graft in the
depths of the wound can be used but is usually unnecessary.
The umbilicus is lled with a greasy gauze tie-over bolster dressing. This dressing
is left in place for 5 days. Complete healing usually occurs in 10 to 14 days.
2 cm
After Illouz
Anterior
rectus sheath
Anterior
rectus sheath

Scarring
Another minor problem following TRAM free ap harvest involves the abdominal
scar. The scar may be widened or hypertrophic and require simple excision and
layered closure. Occasionally, painful sutures may bene t by excision. In addition,
not infrequently a small dog-ear is present at either end of the abdominal scar.
These dog-ears can be elliptically excised and the wounds closed, creating a
smoother contour of the abdominal scar.
THIGH FLAP
Unilateral harvest of a lateral transverse thigh ap virtually always results in asym-
metry of the trochanteric areas. Bilateral harvest is most frequently complicated by
over-resection of fat and resultant depressions.
1471
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
This 53-year-old patient required bilateral mastectomy and desired breast recon-
struction using autogenous tissue. She was not a candidate for TRAM ap recon-
struction because of multiple abdominal scars. On different days during the same
hospitalization she underwent bilateral mastectomy and reconstruction using lateral
transverse thigh aps. Although the shape and symmetry of the breast reconstruc-
tion are satisfactory, the depressions left by overzealous harvesting of the thigh fat
are quite apparent. This deformity is almost impossible to fully correct. Some ad-
ditional liposculpturing could smooth out the surrounding area. Fat injection
would be insuf cient to ll the defects in this case.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
A lateral vertical thigh ap causes the same problem if only a unilateral ap is har-
vested. However, a bilateral harvest of this ap improves the contour of the lateral
thighs. The trade-off is a visible vertical scar similar to that which occurs with
femoral osteotomies. However, the patients we have treated seem to accept this scar
better than the scar following harvest of the lateral transverse thigh ap. Contour
deformities that occur following harvest of the lateral vertical thigh ap can some-
times be treated with the transfer of local aps. A small ap of subcutaneous fat
designed in an area of excess fat is transposed into the area of de cit.
This 40-year-old patient required bilateral mastectomy and reconstruction. She de-
sired autogenous reconstruction, and lateral vertical thigh aps were used because
she had insuf cient abdominal tissue.
Comparing the preoperative and postoperative contours of the donor site demon-
strates a more acceptable appearance than that following the harvest of the lateral
transverse thigh ap. Nevertheless, a minor revision was required using a small ap
of subcutaneous fat transposed into a surface contour depression.

GLUTEAL FLAP
Planning errors with the gluteal ap can result in wide, visible scars. Misplaced scars
are not easily treated by any scar revision technique.Widened scars can be excised
and reclosed in layers.When the superior gluteal ap is designed to be more trans-
verse and in a lower position, the scar is more easily concealed. Similarly, the har-
vest of the inferior gluteal ap ideally should leave the scar in the infragluteal fold,
where it is well hidden.
Unilateral ap harvest will always result in some asymmetry. The less tissue har-
vested, the more symmetrical the nal result will be. If the asymmetry is marked,
opposite buttock liposuction will help balance it. Direct excision of the opposite
buttock is a less preferable option;the patient must be willing to accept a contralat-
eral scar.
NERVE INJURY
Peripheral nerve injuries can occur in free ap breast reconstruction as a result of
intraoperative positioning. In the upper extremity these may be noted during the
early postoperative period. For TRAM ap harvest and transfer the arms should be
positioned on arm boards at no more than 90 degrees of abduction.
1473
Chapter 37
Reoperation Following Free Flap Breast Reconstruction
Careful padding and positioning of the arms is essential to prevent
compression or stretch of the brachial plexus.
The elbows should be slightly exed, and the forearms should be in the neutral
position, neither supinated nor pronated. Prevention of nerve injuries is the best
course.

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R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
If neurapraxia occurs, conservative treatment is usually indicated. Patients with pre-
existing but possibly asymptomatic compression neuropathies are at risk for this
problem. With diminished axonal ow caused by pressure on the brachial plexus,
patients may become symptomatic at the distal site of preexisting compression from
a “double crush injury.” Most minor neurapraxias resolve within 30 days. If they
persist, a baseline electromyogram and a nerve conduction study are indicated. Usu-
ally, however, even recalcitrant neurapraxias will completely resolve. If the patient
remains symptomatic and unimproved at 3 months, nerve release at the speci c
point of compression is indicated.50
In the lower extremity, sciatic nerve neurapraxia may be noted following inferior
gluteal ap harvesting. Again, this is generally caused by intraoperative positioning
and will virtually always resolve with conservative treatment.
CONCLUSION
Although free ap breast reconstruction has greatly increased in popularity among
microsurgeons, the initial ap transfer represents only the rst step toward a satis-
fying result. Most often, a planned second-stage breast mound revision coupled
with skillful nipple-areola reconstruction will provide excellent symmetry, partic-
ularly with immediate breast reconstruction.The reconstruction of a sensate breast
remains investigational. Similarly, some surgeons are working toward a one-stage to-
tal breast reconstruction, including the nipple-areola complex. In the meantime,
mere mortals must be prepared to reoperate in the quest for perfect results.
References—With Key Annotated References
1. Keith DJ,Walker MB,Walker LG, et al.Women who wish breast reconstruction: Characteris-
tics, fears, and hopes. Plast Reconstr Surg 111:1051-1056; discussion 1057-1059, 2003.
The aims of this study were to identify the characteristics of a consecutive series of women with newly
diagnosed breast cancer and to evaluate the perceived bene ts and disadvantages of breast reconstruc-
tion. A consecutive series of 125 women completed the Breast Reconstruction Questionnaire, the
Hospital Anxiety and Depression Scale, and the Eysenck Personality Questionnaire.
2. Cocquyt VF, Blondeel PN, Depypere HT, et al. Better cosmetic results and comparable qual-
ity of life after skin-sparing mastectomy and immediate autologous breast reconstruction com-
pared to breast conservative treatment. Br J Plast Surg 56:462-470, 2003.
3. Blondeel PN, Boeckx WD. Re nements in free ap breast reconstruction: The free bilateral
deep inferior epigastric perforator ap anastomosed to the internal mammary artery. Br J Plast
Surg 47:495-501, 1994.
Beside the enormous advantages of reconstructing an amputated breast by means of a conventional
TRAM ap, the main disadvantage is the elevation of small (free TRAM) or larger (pedicled TRAM)
parts of the rectus abdominis muscle.To overcome this disadvantage, the free deep inferior epigastric per-
forator (DIEP/DIEAP) skin ap has recently been used for breast mound reconstruction with ex-
cellent clinical results. After achieving favorable results with eight unilateral DIEP/DIEAP aps, we
were challenged by an abdomen with a midline laparotomy scar. By dissecting a bilateral
DIEP/DIEAP ap and making adjacent anastomoses to the internal mammary artery, we were