Reoperative Plastic Surgery of the Breast

Implant(s) Cont’d
imaging modalities for, 149, 151–153,
151f, 152f
infection and, 91, 259, 259f
integrity, evaluation, 147–182
malposition, 79, 108, 110–111, 111f,
112f
migration, Prolene sutures and, 271f
pocket, medial implant malposition,
125
position of, 71, 73, 77, 77f
postoperative complications of, 256,
257f, 258f, 259, 260f, 261f, 262f,
263f
postoperative view, 131f
preoperative v. correction, 124f
previous surgery, 46
reconstruction, folds following, 289,
290f
removal, suture closure after, 126f
reoperative surgery and, 4
replacement, 162
round, measurements and, 71, 71f
rupture, 142, 148f
silicone gel implant, breast recon-
struction with, 291
size, upper pole fullness and, 115, 118f
sizer, 79
saline, 79
surface dimensions for, charts for, 72f
suture placement and, 100f
tissue loss in TRAM flap and, 377–378
too high, 111, 113, 114–115
too low, 272
frank inferior malposition, 115, 117,
122f
too small, patient desiring larger size
and, 95, 97, 98f
Implant displacement exercises, subpec-
toral pocket dissection and, 83,
83f
Implant-based breast reconstruction, 32,
284, 285f–286f
difficult patients for, 246, 247f–248f
implant selection for, 242
large volume implants and, 38
preoperative evaluation for, 238–241,
243–245
projection and, 284–285, 285f
skin folds with, etiology of, 287–289,
288t
upper pole of breast, 244f
INAMED tissue expander, 244, 245, 245f
Incisions. See also Axillary incision;
Electrocautery device; Inferior
capsulotomy incision; Infra-areo-
lar incision; Inframammary inci-
sion; Inverted T incision;
McBurney-type oblique abdominal
midline incision; Open incisional
biopsy; Periareolar incision;
Transaxillary incision; Vertical
incision
approaches, breast augmentation and,
71f
breast aesthetics and, 35f–36f
implant malposition, 124, 124f
implant too low, 115
previous, TRAM flap breast reconstruc-
tion, 307
revisional breast surgery and, 48
selection of, 75–76
skin scar and, 43
Incisions Cont’d
skin-sparing mastectomy and, 332f,
333
subpectoral pocket dissection, 79–82
transaxillary breast augmentation and,
76, 76f
Infection
breast augmentation and, 88, 91, 92f,
93, 94f
implant and, 259, 260f
nipple reconstruction and, 459
TRAM flap breast reconstruction and,
353, 355f
Inferior capsulorrhaphy, implant too low,
115
Inferior capsulotomy incision, electro-
cautery device and, 267f–268f
Inferior implant malposition, 125f–126f,
274f–276f, 282
maneuvers for, 117, 121, 122f
saline implant and, 114
Inferior pedical breast reduction, nipple
loss and, 486–487, 486f–487f
Inferior pedicle mastopexy, skin mark-
ings for, 177f
Inferior pedicle technique, 40f, 41
Inferior pole of breast, post-lumpectomy
deformity and, 426
Inferior-medial capsulotomy, 130f
Information gathering, 2
Informed consent
breast augmentation and, 93
obtaining, 6–8
surgical procedures and, 5
Infra-areolar incision, 75
capsular contracture and, 172f
Inframammary (IM) fold, 20
abnormality in, 360, 360f–361f
asymmetries, 102, 104, 108, 109f, 386,
392f–393f
TRAM flap Breast reconstruction
and, 302
breast aesthetics and, 22, 22f, 23, 23f,
26, 27f, 28
breast augmentation and, 77, 77f
deformities in, 30, 31f
establishing definition of, 277,
278f–279f
implant and, 277
internal reconstruction of, 390, 392f
nipple position to, 455, 456f–457f
raising, capsular suture technique, 272,
273f, 274f
scars in, 41, 42f, 49
tightness in, 28f
tissue expander and, correction of, 264,
265, 266f
too high, 386, 389, 390f
too low, 389, 392f
TRAM flap and, 323, 324f, 327–328,
327f
Inframammary incision
capsulectomy and, 159
implant removal and, 155, 155f
Total periprosthetic capsulectomy, 142f
Initial visit, revisional surgery and, 2
Injection, fat cell grafting and, 405
Internal adipose flap, obese patient and,
399, 402f–403f
Internal flaps, 396, 399
Intracapsular rupture, TPPC and, 155
Intradermal tattoo, 299, 299f
areolar area and, 291
Intradermal tattoo, Cont’d
areolar hypopigmentation and, 486,
487
for areolar pigmentation, 282,
283f–284f
nipple projection loss and, 471
nipple areola construction and, 456
options, 459, 459t
Intraductal carcinoma of breast
open incisional biopsy, 333
TRAM flap breast reconstruction and,
353, 354f–356f
Intraparenchymal fibrosis, post-lumpec-
tomy deformity and, 426
Inverted T incision, 155–156
breast reduction and, 60
explantation with mastopexy alone
and, 170
fat necrosis and, 358, 360f–361f
Inverted T mastopexy, 156
Ischemia
of breast skin flaps, 346, 347f, 348
TRAM flap breast reconstruction
and, 302
nipple reconstruction and, 464
radiation therapy and, 428
J
Jackson-Pratt drain
capsulectomy and, 159
hematoma and, 87
medial implant malposition and, 128
seroma and, 163
K
Kerlix roll application, 79
L
Laparotomy, exploratory, TRAM flap
breast reconstruction and, 416,
416f
Lateral breast contour, adipose excess in,
363
Lateral capsular recess, closing, 130f
Lateral implant malposition, 111f, 112f,
121, 124, 125, 129f, 273, 280, 282
Lateral implant subluxation, marking
patient for, 128f
Lateral pocket dissection, limiting, 78
Lateral thigh flap, 414
Latissimus dorsi flaps, post-lumpectomy
deformity and, 426, 426f
Latissimus dorsi muscle, 449, 451f
flap reconstruction, radiation-induced
capsular contracture and, 294,
295f–296f, 296
Lidocaine, fat donor site and, 404
Lipocontouring, 382, 384f
breast volume reduction and, 365f, 366
planning, 467f
Liposuction
adipose volume reduction and, 56f, 59
adjacent contour adjustment and, 368,
368f
superior skin flap and, 299, 299f
TRAM flap and, 362, 362f
Litigation. See also Medical malpractice
breast surgery and, specifics of, 8–9
Lumpectomy, 396, 398f. See also Post-
lumpectomy deformity
both breasts, surgical modification of,
442, 443f–444f
breast asymmetries and, 429
492
Index

Lumpectomy, Cont’d
combined deformities and, 62–63
contralateral breast, surgical modifica-
tion of, 440, 441f
defect
breast cancer and, 420, 421f, 422f
plastic surgery reconstruction and,
425
deformity, 424f
reoperative surgery following,
420–453
scars following, 429, 430f–431f
skin loss and, 259, 263f
M
Macromastia, 442
Magnetic resonance imaging (MRI),
breast implants and, 149, 153
Malpractice insurance companies, 5
Mammary ptosis. See Ptosis of breast
Mammary ridge, 19, 19f
Mammography, breast implants and,
149, 151f
Marking. See Skin marking
Mastectomy. See also Completion mas-
tectomy
breast reconstruction and, 287f, 384
IM fold asymmetry and, 394f–395f
IM fold in, 328, 328f
previous incision and, 43
skin envelope and, 331, 332f
skin loss and, 259, 263f
skin template for, 329, 329f
Mastectomy flap necrosis, 343
cigarette smoking and, 341, 341t
Mastectomy skin flap
delayed breast reconstruction, 333,
334–335, 334f
resection, 342
seroma fluid and, 256
Mastopexy, 9. See also Augmentation
mastopexy; Vertical mastopexy
breast cancer and, 445, 447f
malpractice insurance companies
and, 5
nipple loss following, 486–487
revision surgery following, 183–235
skin marking for, 174f
McBurney-type oblique abdominal mid-
line incision, TRAM flap breast
reconstruction and, 307
Medial breast constriction deformity, 30,
31f
Medial dissection, 77, 78f
Medial implant malposition, 125,
128–129, 282, 282f
correction schematic for, 133f
Medial inferior capsulotomy, 130f
Medical malpractice
risk minimization of, 6
scope of, 5–6
Medical records, operative plan and, 2
Mesh. See also Prolene mesh; Synthetic
mesh
bipedicle TRAM flap reconstruction
and, 321f
Midabdominal TRAM flap reconstruc-
tion, technique for, 319, 320f, 321
Modified fishtail flaps, 282, 284f
Modified radical mastectomy, early
debridement and, 351, 351f–352f
Modified skin-sparing mastectomy, 282,
284f
Modified star flap nipple reconstruction,
360, 360f–361f, 461f, 463f–464f,
468–469, 471, 472, 473f, 474f, 483f
planning, 467f
Mondor’s disease, 94–95
Multiple capsulotomy technique, capsu-
lar contracture, 141f
Multiple focal capsulectomy, 284
Multiple reconstructive modalities, sub-
optimal result revision with, 396,
400f
Muscle pedicle atrophy, treatment, 386
Musculocutaneous flap, total mastec-
tomy and, 445
N
NAC. See Nipple areolar complex
Native breast skin, loss, immediate
reconstruction and, 341–343
Native breast skin flap necrosis, con-
tributing factors, mastectomy and,
341t
Nipple
breast reconstruction and, 455, 456f
dislocation, 391f
lumpectomy and, 60f, 62–63
incorrect inclination, 484, 485f
loss, 9
mastopexy, 486–487
post breast reduction, 486–487
subtotal, 472–475
total, 472–475
positioning, 23, 24f
sensation, 9
Nipple areola reconstruction
difficult case, planning, 465, 467, 468
interdermal tattoo and, 456
TRAM flap and, 357f–358f
Nipple areolar blood supply
implant effect on, 47–48, 47f
subglandlular implant, 170f
Nipple areolar complex (NAC)
asymmetry and, 62, 63f
blood supply, 48
breast aesthetics and, 20, 21f, 33,
59–62, 379, 382
contour abnormalities in, 429, 432
contralateral breast and, visual symme-
try and, 456
dislocation, post-lumpectomy defor-
mity and, 441f, 445, 446
downsizing, 61–62
malpositioned, 443
orientation, breast asymmetries and,
101–102, 103f
position
breast asymmetries and, 101–102,
103f
breast cancer treatment and, 420,
421f, 422f, 423f
postoperative appearance of, 37, 37f
reconstruction, revision of, 455–488
tumor location v., 423, 424f
tumor resection and, 426
Nipple position
estimating, patient height and, 171t
implant too low, 117f
incorrect, 477–478
nipple areola construction and, 456
plan for, 466f–467f
volume discrepancies and, 62–63
Nipple projection, 456, 458f, 473, 479f
flap and, 461
Nipple projection, Cont’d
loss, modified star flap and, 475,
475f–476f, 479f
Nipple reconstruction, 291, 292f–293f,
299, 299f–300f, 382
double-opposing sliding periareolar
flap and, 477
options, 459–461, 459t
planning, 462–464, 466f
skin marking and, 462–464, 466f
skin-sparing mastectomy and, 57f, 61
suboptimal, revision of, 471
surgical technique for, 464–465
techniques, 468–471
Nipple retraction, oncoplastic surgical
treatment for, 442, 443f
Nipple sharing, nipple reconstruction
and, 460, 460f
Nipple symmetries, post-lumpectomy,
449, 452f–453f
Nonsteroidal anti-inflammatory drugs
(NSAIDs), Mondor’s disease and,
95
NSAID. See Nonsteroidal anti-inflamma-
tory drugs
O
Obese patient
internal adipose flap and, 399
superior implant malposition and, 280
TRAM flap breast reconstruction and,
307, 308f, 321
Office chart, informed consent and, 7
Oncology, breast, 424, 425
Oncoplastic surgery, post-lumpectomy,
442–443, 444f
Open incisional biopsy, intraductal carci-
noma of breast and, 333
Open wounds. See Wound(s)
Operating room notes, patient documen-
tation and, 8
Operative plan
communication and, 2
implant reconstruction and, 289, 290f
Opsite dressing, 79, 80f
infection and, 91
Oxicillin, TRAM flap breast reconstruc-
tion and, 353, 354f–356f
P
Pain, breast augmentation and, 9
Partial dermal excision, downward nip-
ple inclination and, 484, 484f
Partial flap loss, TRAM flap and, 377
Partial mastectomy defects, reconstruc-
tion of, 449
Partial retropectoral position, 166, 169f
Patient. See also Physical examination
documentation, operating room notes
and, 8
education, 3
evaluation, 6
breast augmentation and, 67–68
expectations, 2–3
history
implant integrity and, 147–148
reoperative breast augmentation
and, 83–85, 84t
informed consent and, 7
surgeon and, reoperative plastic sur-
gery and, 1–2
Pectoralis major muscle (PMM)
breast aesthetics and, 28, 29f
Index
493

Pectoralis major muscle (PMM) Cont’d
physical examination and, 149
subpectoral pocket dissection and,
79–80, 81f, 82, 82f
tissue expander placement and,
251–252, 252f
Pectus excavatum, 32, 33f
Pedical flap transfer, flap loss after, 414
Pedicled TRAM flap, 321, 322f–323f,
377
autogenous conversion and, 179f, 180,
181f
suboptimal projection and, 399, 404
Periareolar incision, 75f
breast cancer and, 332f, 333
constricted breast deformity and, 75f
implant removal and, 155, 155f
skin-sparing mastectomy and, 332f
Periprosthetic capsular space
double capsular flap technique for,
123f
hematoma and, 87
implant disproportion and, 289, 290f
plication sutures and, 273f, 276
revision, device dimension and, 269,
269f–270f
suture capsulorrhaphy closure and,
133f
Periprosthetic capsular surgery, 46–47
Periprosthetic capsule
finger dissection and, 159f
management of, 155–158
suture placement, 273f
Periprosthetic capsulectomy, cellulitis
and, 92f
Permanent monofilament suture,
implant and, 272, 273f
Photographic documentation
patient documentation and, 8
reoperative surgery and, 4–5
Photographs, implant choice and, 69f
Physical examination
implant integrity and, 148–149
reoperative breast augmentation and,
83–85, 84t
Pigmentation, nipple areola construction
and, 456
Pinch test
breast parenchyma and, 74f
implants and, 162f
Plastic surgeon, post-lumpectomy defor-
mity and, 425–429
Plastic surgery reconstruction, lumpec-
tomy defect and, 425
PMM. See Pectoralis major muscle
PMT. See Dual chamber saline tissue
expander
Pocket dissection, 77, 77f
implant insertion and, 79, 80f
implant too high with, 111
Pocket reassignment, medial implant
malposition and, 128, 133f
Polyurethan-covered implants, TPPC
and, 157
Post-lumpectomy
both breasts, surgical modification of,
442, 443f
oncoplastic surgical treatment for,
442–443, 444f
Post-lumpectomy deformity, 419f, 420,
422f, 423f, 425–429
flaps and, 445–446
treatment approach, 425t
Postlumpectomy plus radiation defor-
mity, 435–436
Postlumpectomy reconstruction,
implants for, 435f–436f, 436, 436f,
437f–438f
Postoperative management, subpectoral
pocket dissection and, 83
Post-radiation, latissimus dorsi flap and,
294, 295f–296f, 296
PPCS. See Periprosthetic capsular space
Pregnancy
breast parenchyma and, 20, 21f
mammary ptosis and, 38
Preoperative evaluation, implant breast
reconstruction and, 238–241
Preoperative imagery, breast aesthetics
and, 18
Preoperative marking, breast augmenta-
tion and, 121
Preoperative planning
errors in, TRAM flap Breast recon-
struction and, 302, 303t
factors in, implant choice and, 68
immediate breast reconstruction,
364f–366f
inadequate, problems in, 95
nipple reconstruction, 462–464, 466f
TRAM flap Breast reconstruction and,
302
Procedure selection, fat necrosis and,
405
Projection loss
double opposing tab flap and, 471
nipple reconstruction and, 461, 468
Projection of breast
implant breast reconstruction and,
284–285, 285f
nipple areola construction and, 456
TRAM flap revision, 395
malpositioned volume and, 390
TRAM flap tissue and, 389
volume deficit and, 399, 404
Prolene mesh, abdominal wall hernia
and, 416, 416f, 418, 418f, 419
Prolene sutures, Implant migration and,
271f
Prosthetic infections, 91
Ptosis of breast, 24, 38, 396, 397f
age and, 21f
weight gain and, 388f, 395
Puberty, breast gland at, 19–20, 21f
Pullout skin flaps, nipple reconstruction
and, 459, 460, 460f, 461f
Purse string closure, 474, 478f
double-opposing sliding periareolar
flap, 477
Q
Quadripod flap, nipple reconstruction
and, 460, 461f
R
Radiation therapy, 396, 398f. See also
Post-radiation
both breasts, surgical modification of,
442, 443f–444f
breast asymmetries and, 429
contralateral breast, surgical modifica-
tion of, 440, 441f
poor outcome and, 423
post-lumpectomy deformity and, 440f,
445, 446
postoperative breast with, 391f
Radiation therapy, Cont’d
reoperative surgery following, 420–453
skin loss and, 259, 263f
staged tissue expander-implant recon-
struction and, 296
tissue expander and, 240f
Radiation-induced capsular contracture,
autogenous tissue supplementa-
tion, 294, 295f, 296
Radiation-induced tissue loss, 429
Recalcitrant capsular contracture, TRAM
flap and, 288
Reconstructive plan, TRAM flap, 280f
Rectus abdominis muscle fascia
abdominal wall closure and, 337–338
excision, inferior medial bulge correc-
tion and, 368
flap procedures and, 325–327, 325f,
326f
tissue expander placement and,
251–252, 252f
TRAM flap and, 404, 404f
Reoperation breast surgery. See
Revisional breast surgery
Revision Breast Augmentation Consent
Form, 11
Revision Breast Reconstruction with
Synthetic Implant Consent Form,
12
Revision of Augmentation Mastopexy
Consent Form, 14
Revision of Breast Reduction Consent
Form, 16
Revision of Mastopexy Consent Form, 13
Revision of TRAM Flap Breast
Reconstruction Consent Form, 15
Revisional breast surgery
aesthetic priorities in, 48–62
anatomic considerations with, 184
breast reduction and, 183–235
deciding against, 3–4
following lumpectomy, 420–453
following radiation therapy, 420–453
mastopexy and, 183–235
overview of, 84t
post-lumpectomy deformity and, 426
primary surgery v., 1, 9–10
proceeding with, 4
reasons for, 48t
Ripples, ridges and folds. See Skin wrin-
kling
Rotational deformity of chest wall,
breast aesthetics and, 33, 34f
Round implants, 287
Rubens flap, 414
S
Saline implant, 110
capsular contracture and, 137
implant deflation and, 291
postoperative view, 113f, 114f
studies, 108
subpectoral position for, 73
Scar hypertrophy, 42–43, 42f, 49, 49f
Scar tissue, 9, 48
breast aesthetics, 379, 382
contour abnormalities, adipose tissue
and, 432
double opposing tab flap and, 470
flap site and, 414
IM region, 49
immediate breast reconstruction v., 333
invagination of, 49
494
Index

Scar tissue, Cont’d
invagination of skin and, 444f
lumpectomy and, 429, 430f–431f
malpractice insurance companies and, 5
nipple reconstruction and, 460, 460f,
467, 468f
position, breast reconstruction and, 35,
35f
post-lumpectomy deformity and, 426
post-lumpectomy patient and, 443
reoperation and, 41–43, 41f, 42f, 298
revisions, 4
shape of, revisional breast surgery, 382
transaxillary approach and, 75–76
Scarp’s fascia. See Superficial fascia sys-
tem
Scoliosis, breast asymmetry and, 32, 34f
Secondary nipple reconstruction, 445,
446
Selective cerebration, 7
Sensory nerve damage, malpractice
insurance companies and, 5
Seroma
breast augmentation and, 88
textured implants and, 141
tissue expander and, 256, 258f
TRAM flap breast reconstruction and,
356
Seroma fluid, mastectomy flaps and, 256
SFS. See Superficial fascia system
Shape of breast
elasticity and, 24
explantation and mastopexy only and,
173f
internal sutures and, 390
problems with, contour and, 50,
51f–52f
revisional breast surgery, 382
TRAM flap and, 310f, 311f, 323, 324f
visual aesthetics and, 37–38
Sharp’s fascia. See Superficial fascia sys-
tem
Short skin flap, lateral implant malposi-
tion and, 280
Short-height tissue expanders, 253, 254f
lower pole and, 253
superior capsulotomies and, 249f
tissue expansion and, first-stage recon-
struction with, 248–250, 248f
SIEA. See Superficial inferior epigastric
artery
Silicone gel implant
intracapsular rupture of, 153
leak, capsulectomy and, 159
rupture, 155
breast reconstruction with, 291
safety of, 66
skin wrinkling, 132
Silicone granuloma, skin markings pre-
operatively and, 167f
Single chamber saline tissue expander,
244, 245f
Single pedicle TRAM flap, 364f–366f
tissue area and, 306f
Size change
minimizing operations for, 97
patient desiring larger size and, 95, 97,
98f, 99f
Skate flap, 473
areola construction and, 464
nipple reconstruction, 461, 462f,
463f–464f, 468
technique for, 469
Skin. See also Abdominal donor site;
Breast skin; Scar tissue; Skin
deficit measurement
breast and, 24–25
necrosis, 43, 351, 351f–352f
split-muscle bipedicle TRAM flap
and, 345
radiation and, 424
radiation therapy injury, 240f
reoperative surgery and, 298
stretching, breast reconstruction tissue
expansion and, 248
TPPC and, 157, 158, 158f
volume loss of, debridement and, 377,
377f
Skin deficit measurement, TRAM flap
Breast reconstruction and, 303,
304f–305f
Skin dimensions, asymmetries and, 39,
40f
Skin envelope, 406
asymmetry, 39–41, 382, 384, 386, 387f
breast aesthetics and, 20
breast volume adjustment, by excision,
386, 388f
contralateral breast and, 333
immediate breast reconstruction and,
331, 332f
reduction, 335, 336f
TRAM flap breast reconstruction and,
328–330, 329f
Skin excision, template of, 384, 386f
Skin flap. See also Breast skin flaps;
Specific type Skin flap i.e. Bell
flap
breast reconstruction and, 35, 35f, 36f
donor site, 414
explantation with mastopexy alone,
171f
loss, TRAM flap revision and, 407,
409–410, 414
necrosis, 343
reconstruction, post-lumpectomy
deformity and, 426
selection, improper, 346, 347f
skin loss at, 53, 54f–55f
vascular perfusion assessment, 342
Skin folds
implant breast reconstruction and,
287–289, 288t
implant reconstruction and, 289, 290f
Skin graft, areola construction and, 464
Skin hooks, nipple reconstruction, 464
Skin loss
breast incisions and, 348
fat necrosis and, 358, 360f
immediate breast reconstruction with
TRAM flap and, 343
implant and, 259
malpractice insurance companies and, 5
management of, TRAM flap recon-
struction and, 344–346, 344f–345f
scar spreading and, 53, 53f, 54f–55f, 56
TRAM flap and, nonoperative manage-
ment of, 345t
Skin marking
adipose tissue volume excess, 362, 362f
post surgical, 363f
capsular modifications and, 250
contour deficit and, 404
delayed breast reconstruction with
tissue expander placement and,
255, 255f
Skin marking Cont’d
graft template, 432–433
hernia and, 416, 416f, 417f
inferior pedicle mastopexy and, 177f
lateral implant subluxation, 128f
malposition and, 274f–276f
mastopexy and, 174f
nipple reconstruction and, 462–464,
466f
silicone granuloma and, 167f
skate design flap and, 469
tissue expander placement and, 250,
251f
Skin paddle, 384, 406
breast aesthetics and, 379, 382
breast reconstruction and, 329,
330f
reduction, 386, 387f
Skin pigmentation, loss of, 9
Skin scars. See Scar tissue
Skin template
mastectomy and, 329, 329f
TRAM flap breast reconstruction and,
311, 312f
Skin tissue deficiency, breast asymmetry
and, 39, 41
Skin ulceration. See Ulceration
Skin wrinkling, 287
breast implantation multifactorial and,
etiology of, 132t
etiology of, 132
theories on, 132, 134
frequency of, 134
implant edge palpability and, 135f
minimizing, 134
surgery and, 134, 136
Skin-sparing mastectomy, 351,
351f–352f, 382, 383f, 387, 388f
immediate breast reconstruction and,
343, 343f
incision designs, 332f, 333
intraductal carcinoma of breast and,
333
TRAM flap and, 57f, 61
Smooth-walled breast implants
postoperatively, 137f
rippling and, 288
SNN. See Suprasternal notch
Snowstorm
breast implants and, 149
intracapsular rupture and, 153f
Soft tissue
padding, skin wrinkling and, 289
tissue expander placement and, 250
Sonography, breast implants and, 149,
152f
Spine, bony anatomy of, 32, 33f
Split-muscle bipedicled TRAM flap
contralateral breast and, 349f
elevation, 320f
skin necrosis and, 345
Stacked TRAM flap, 366, 367f
Staged reconstruction with tissue
expander, TRAM salvage and,
implant for, 378–379, 379f
Staged tissue expander-implant recon-
struction, soft tissue envelope and,
271
Standard profile implant, 73f
Staphylococcus aureus, breast augmenta-
tion and, 88, 91
Staphylococcus epidermidis, capsular
contracture and, 375
Index
495

Star flap
donor area and, 463f, 464
nipple reconstruction, 463f–464f, 464
Stepladder sign, intracapsular rupture
and, 153f
Step-off deformity, 102f
Sterile foam donut, reconstructed nipple
and, 467f
Sterile needle aspiration, seromas and,
256, 257f
Steroid injections, skin scar and, 43
Streptococcus, infection and, 259, 259f
Striae, ptosis and, 25
Subglandlular implant, NAC and, blood
supply to, 170f
Subglandular pocket dissection, 79, 80f
Subglandular silicone gel implants, pre-
operative, 161f
Subglandular space
implant position and, 71, 73, 73f
suturing, 163f
Subglandular to subpectoral space con-
version, 128
Submuscular space, implant position
and, 71, 73, 73f
Subpectoral pocket dissection, 79–82
postoperative management of, 83
Subpectoral space, pocket dissection
and, 79, 80, 81
Suction drain, seroma and, 356
Suction-assisted liposuction with syringe
aspiration, adipose tissue reduc-
tion and, 362
Superficial fascia of chest, suture and,
110f
Superficial fascia system (SFS or Scarp’s
fascia), peri-prosthetic capsule
and, 277, 278f–279f
Superficial inferior epigastric artery
(SIEA), TRAM flap and, 314, 315f
Superior capsulotomies, short-height tis-
sue expanders and, 249, 249f
Superior implant malposition, 112f
of expander, 271, 272f
obese patient and, 280, 281f
Superior incision, internal adipose flap
and, 399, 402f–403f
Superior pedicle mastopexy technique,
170
Superior pole rippling, correction, 291,
292f–293f
Superior skin flap, liposuction of, 299,
299f
Supermedial translocation of flap, 382,
384f
Supranumerary nipple, 19, 19f
Suprasternal notch (SNN), breast aes-
thetics and, 22, 23–24
Surface dimensions, implants and,
charts for, 72f
Surgeon. See also Plastic surgeon
patient and, reoperative plastic surgery
and, 1–2
Surgery. See also Periprosthetic capsular
surgery; Postoperative manage-
ment; Preoperative planning;
Revisional breast surgery; Specific
type Surgery i.e. Periprosthetic
capsular surgery
litigation and, specifics of, 8–9
planning and technique, breast aug-
mentation and, 77–79, 77f, 78f, 79
skin wrinkling and, 134, 136
Surgical debridement. See Debridement
Surgical excision, radiation v., 424
Surgical technique, nipple reconstruc-
tion and, 464–465
Survival, breast-conserving therapy and,
420
Suture(s). See also Chromic sutures;
Fixation sutures
closure, implant removal and, 126f
IM fold, 393f
implant malposition, 124, 124f
internal, breast shape, 390, 393f, 395f
medial implant malposition, 282, 282f
nipple reconstruction and, 464
periprosthetic capsular space, 289, 290f
placement, implant malposition and,
100f
plication, periprosthetic capsule, 273f
subglandluar space and, 163f
superficial fascia and, 110f
Suture capsulorrhaphy closure
capsular space and, 100f
implant too low, 117, 120f
lateral implant malposition and, 280,
282
Symmastia, 125, 136, 137f, 282, 284f
Symmetry of breast(s), 36–37, 299f–300f,
300, 381f–382f
breast reconstruction and, 372,
373f–374f
IM fold and, 389
post-lumpectomy patient and, 443,
443f, 445f
procedures for, 366, 367f
silicone implant and, 164, 164f, 165f
TRAM flap and, 353, 354f–356f
Synthetic implant-based reconstruction,
donor tissue for, 246
Synthetic mesh, abdominal wall closure,
337–338, 338f
T
T skin excisional pattern, 395
Tactile sense, breast aesthetics and, 18
Tailor tacking technique, 157f
breast reshaping and, 36, 37f
mastopexy and, 172f
scar and, 41f
Tattooing. See also Intradermal tattoo
areola construction and, 465, 465f
problems with, 485
TEPID system, 110
Textured shaped implants, 244
Textured silicone gel implants, tissue
expansion and, 287, 288f
Textured-surface implants
medial implant malposition and, 134
seroma and, 141
Thin patient, TRAM flap breast recon-
struction and, 308, 309f–310f
Thoracic adipose tissue, thick, superior
implant malposition and, 280
Thoracodorsal vessels, TRAM flap and,
317f–318f
Thorax, bony anatomy of, 32, 33f
Thrombophlebitis of axillary veins,
NSAIDs and, 85f, 95
Timing, reoperative surgery and, 4
Tissue expander. See also Short-height
tissue expanders
breast cancer and, 449, 450f
breast reconstruction and, 372,
373f–374f
Tissue expander. Cont’d
hematoma, 256, 257f
implant breast reconstruction and, 242,
243
lower pole, correction of, 264
malposition, 264–265, 264f, 266f
nipple loss and, 471, 471f
placement, postoperative complications
of, 256, 257f, 258f, 259, 260f, 261f,
262f, 263f
placement techniques for, 250–253
position, 251f
reinsertion, inadequate implant recon-
struction and, 269, 269f–270f
seroma and, 256, 258f
skin stretching and, 248
too low, 272
types of, 244, 245f
Tissue expander-implant reconstruction,
nipple projection loss with,
482f–483f
Tissue expansion, 280f
breast reconstruction and, 285f
Tissue loss in TRAM flap, implant for,
377–378
Tissue zones, adipose fat and, 405
Total breast size, tumor size v., 423, 424f
Total capsulectomy, capsular contrac-
ture, 141, 141f
Total mastectomy, musculocutaneous
flap and, 445
Total periprosthetic capsulectomy
(TPPC)
IM incision for, 142f
incisions for, 155
intracapsular rupture and, 155
medial implant malposition and, 128
TRAM flap (Transverse rectus abdomi-
nus muscle flap). See also Pedicled
TRAM flap
post-lumpectomy deformity and, 55f,
58, 60f, 62f, 63, 178, 298, 382, 426,
426f
abdominal wall hernia and, 416,
416f
acute complications following, 341
adipose tissue
reduction and, 362
volume in, 370
autogenous tissue conversion, 291,
292f, 297, 297f–298f
following suboptimal implant-
based reconstruction and, 180,
181f
avoiding complications in, 302–339
circulation to, 314t
complications following, 341, 341t
donor site problems for, 414, 414f,
415f, 416, 417f, 418–419
fat necrosis and, 405–406, 406,
406f–407f
final assessment of, 335
flap loss following, 407, 409–410,
414
harvest, 414
mesh in, 337
synthetic mesh application in,
416, 416f
hematoma and, 353
IM fold in, 327–328, 327f
infection and, 259, 259f
loss, gluteus maximus musculocu-
taeous flap and, 414, 414f–415f
496
Index

TRAM flap Cont’d
midabdominal, 315f
patient selection in, 303t, 306–308
planning, 323
post-lumpectomy, 449, 452f–453f
procedure selection, 303, 303t, 305
projection and, 395
recalcitrant capsular contracture
and, 288
recurrent hernia and, 419
skin paddle, autogenous conversion
and, 291, 292f–293f
skin-sparing mastectomy and, 57f,
61
staged tissue expander-implant
reconstruction and, 296
tissue, projection of, 389
volume excess and, 362–363, 366
zones, 305, 305f
TRAM flap (Transverse rectus abdomi-
nus muscle flap) revision, projec-
tion and, lower TRAM flap pole,
404f
TRAM flap (Transverse rectus abdomi-
nus muscle flap) volume
augmenting, adjacent tissue and, 396,
400f
deficiencies with, 378
insuffiicency and, 372, 375, 375f
TRAM skin paddle inset, 343, 343f
Transaxillary breast augmentation,
bleeding and, 76
Transaxillary incision, subpectoral
pocket dissection and, 82, 82f
Transmidline tissue, 346, 347f
TRANS flap and, 346, 347f
Transverse rectus abdominis muscle
flaps. See TRAM flap
Tubular breast deformity, 30, 31f
Tumor
excision, poor outcome and, 423
resection, NAC and, 426
size, breast-conserving therapy and,
423, 424f
U
Ulceration, 428f, 429
necrotic, radiation therapy and, 427,
428f
Unipedicle superiorly based flap, TRAM
flap as, 305, 305f
Upper breast pole, TRAM flap and,
389
V
V to Y closure method, 377, 377f
nipple position and, 478
Vascular insufficiency, TRAM flap Breast
reconstruction and, 302
Vascular ischemia, mastectomy flap
necrosis and, 341, 341t
Vascularized tissue, post-lumpectomy
deformity and, 426
Vasculitis, radiation therapy and, 429
Venous circulation, TRAM flap and, 313,
314f, 314t
Vertical breast shape, TRAM flap breast
reconstruction and, 310f
Vertical incision
abdominal wall hernia and, 416, 416f
mastopexy and, 172f
TPPC and, 156f, 157f
Vertical inset, flap and, 323, 326f
Vertical mammoplasty technique,
projection of TRAM flap with,
396, 397f
Vertical mastopexy, 440, 441f
contra lateral breast and, 241,
241f–242f
postoperative, 175f, 440, 441f
Vertical oblique shape, TRAM flap breast
reconstruction and, 310f
Vertical scar mammoplasty, 171, 173f
Vertical scar technique, augmentation
mastopexy and, 41
Visual aesthetics, breast shape and,
37–38
Visual sense, breast aesthetics and, 18,
18f
W
Weight
mammary ptosis and, 38
skin changes and, 25, 27f
Whole muscle harvest, flap procedures
and, 325, 325f
Wise incisional pattern. See Inverted T
incision
Wood’s lamp, vascular perfusion assess-
ment and, 342
Worksheet, breast evaluation and, 148,
150f
Wound(s). See also Acute wounds
abscess, TRAM flap breast reconstruc-
tion and, 353, 355f
contraction, 472
nipple reconstruction and, 461, 464
debridement, 353
dehiscence, 96f
breast augmentation and, 93–94, 96f
dressing, skin loss, TRAM flap recon-
struction and, 344
healing, 346, 347f
double opposing tab flap and, 470
radiation therapy and, 427, 427f
reoperative surgery and, 4
management, 351
skin loss and, 259, 262f
native skin flap necrosis and, 342
nipple reconstruction and, 459, 461
open
debridement of, TRAM flap breast
reconstruction, 348, 349f–350f,
351
nipple position and, 478
reconstructed breast and, 351
split-muscle bipedicle TRAM flap
and, 345
reclosure, skin loss and, TRAM flap
reconstruction and, 344
repair, timeline of, 428
Wound care, skin loss and, TRAM flap,
346
Index
497