Reoperative Plastic Surgery of the Breast

392
Reoperative Plastic Surgery of the Breast
FIGURE 8-28. A, IM fold asymmetry with poor definition and
inferior flap malposition following immediate left breast recon-
struction with a unipedicle, ipsilateral rectus TRAM flap. B, The
examiner simulates correction by gentle digital pressure placed
against the skin in the lower breast pole, displacing the TRAM
flap superiorly. C, Marks are made on the skin in areas where the
fold will be recreated using internal suturing. (continued)

FIGURE 8-28. (CONTINUED) D, The lower pole of the TRAM flap is dissected free on its superior,
inferior, and posterior surfaces and folded underneath the middle pole to increase projection. The supe-
rior repositioning and reconstruction of the fold is done with internal sutures. E, Technique of suture
placement for internal reconstruction of IM fold. F, The correction achieved at surgery. G,
Postoperative correction illustrating symmetric IM folds. This case illustrates the powerful effect the IM
fold has on the shape and projection of the breast.
Internal IMF reconstruction
Pectoralis fascia
Ribs
IMF
3-0 PDS
E

FIGURE 8-29. A, Preoperative appearance of the breast in a patient who requires a mastectomy to
treat a breast cancer recurrence following lumpectomy and radiation therapy. B, Immediate right
breast reconstruction with unipedicle contralateral rectus muscle TRAM has resulted in a marked
asymmetry of the IM folds. (continued)
Deepithelized
TRAM fat flap
tucked under
skin
TRAM skin for
new breast
TRAM flap fat
tucked under
a
b
c
a
b
c
D

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
395
jection, and upper pole fullness of the breast. This influ-
ence of the IM fold is true in both aesthetic and reconstruc-
tive breast surgery. It has a profound effect on both
implant cases and TRAM flap breast reconstructions.
INCREASING FLAP PROJECTION
FOLLOWING TRAM FLAP
RECONSTRUCTION
Increasing the projection of the breast following TRAM
flap reconstruction can be done by placing an implant
beneath the flap (see Figs. 8-17 and 8-18), by elevating the
flap from the underlying chest wall and folding the infe-
rior portion underneath the central portion of the flap as
discussed (Fig. 8-27D and 8-29D), or by bringing the
medial and lateral pillars of the flap together by excising
a central segment as a means of conifying the recon-
structed breast. This is an excellent procedure when a
contralateral breast reduction has been performed.
Making more of a cone out of the breast tissue has long
been used as a means of increasing projection during
mammoplasty, and it is being used more and more as
method of increasing projection following TRAM flap
reconstruction. It is also very easy to reconstruct the
nipple at the time of such a procedure by using tissue on
the edge of either the medial or lateral skin flaps (on
either side of the vertical incision) that would otherwise
be discarded as demonstrated previously (see Fig. 8-
10D,E) and performing a wraparound or fishtail flap or
modified star flap. This technique was used in this
patient who underwent an immediate right breast recon-
struction with an inverted T skin excisional pattern and a
simultaneous left breast reduction also with an inverted T
skin excisional pattern (see Fig. 8-10A). To increase the
projection of the TRAM flap reconstruction she under-
went elevation of medial and lateral skin flaps. The tissue
at the edge of the medial flap was curled on itself in the
form of a fishtail flap (see Fig. 8-10D). Closure of the ver-
tical scar allowed increased projection and improved the
overall breast symmetry (see Fig. 8-10E).
The principle of conifying the breast can be applied to
the TRAM flap breast reconstruction in many settings. It
decreases base width and increases projection and can be
used to elevate nipple position and to decrease the vol-
ume of the breast. This is illustrated in the previously
described patient (see Fig. 8-25A), who developed pro-
gressive ptosis of her reconstructed breast with weight
gain such that it became larger than the opposite breast
(see Fig. 8-25B). There was an associated disparity in the
heights of the nipples. I felt that the best way to enhance
symmetry was to resect skin and breast tissue in both a
vertical and a horizontal dimension (see Fig. 8-25C). This
permitted superior relocation of the NAC and much bet-
ter global symmetry (see Fig. 8-25D).
FIGURE 8-29. (CONTINUED) C, Patient has large rectus mus-
cle outlined along with planned correction. D, Internal suture
correction of the IM fold to be accomplished with Prolene
sutures. E-F, Appearance of IM fold correction following supe-
rior flap mobilization, subtotal rectus muscle transection, and
internal suture technique.

396
Reoperative Plastic Surgery of the Breast
INCREASING PROJECTION OF A TRAM
FLAP BY VERTICAL MAMMOPLASTY
TECHNIQUE
In three patients I have actually used the vertical mammo-
plasty technique23,24 to narrow the base width of the
TRAM flap breast reconstruction and to increase the pro-
jection. This technique can be helpful, but it must be
borne in mind that the TRAM flap adipose tissue is not
endowed with the same abundant vascularity as normal
breast parenchyma. Therefore good judgment must be
exercised when constructing and folding the created adi-
pose flap within the existing TRAM flap. This predomi-
nantly means to leave the base of the flap (oriented
superiorly) of sufficient thickness to ensure adequate vas-
cularity of the internal adipose flap.
The application of the vertical mammoplasty technique
in the setting of a TRAM flap breast reconstruction is
illustrated by this next patient (Fig. 8-30A–E), who had
originally undergone a lumpectomy and radiation for a
right breast cancer. She developed a recurrence that was
treated by a right mastectomy. Because of tissue require-
ments to match her opposite breast, the right breast was
reconstructed with a split-muscle bipedicle TRAM flap.
This produced an appearance of bilateral breast ptosis
and decreased projection (Fig. 8-30A). The plan was for a
bilateral vertical mammoplasty and right nipple recon-
struction (Fig. 8-30B). At surgery the mastopexy was per-
formed on the left breast first. Next a similar procedure
was performed on the TRAM flap with a simultaneous
nipple reconstruction (Fig. 8-30C). This produced a better
appearance on the AP (Fig. 8-30D) and oblique (Fig.
8-30E) views.
The application of this technique in the setting of a
TRAM flap breast reconstruction is further illustrated by
this next patient (Fig. 8-31A–E), who had originally
undergone a left lumpectomy and radiation for breast
cancer. She developed a recurrence that was treated by a
left mastectomy without a breast reconstruction (Fig. 8-
31A). She presented to me with the diagnosis of a multi-
focal right breast cancer, which also required a
mastectomy. She requested a bilateral breast reconstruc-
tion with TRAM flaps at the time of her right mastec-
tomy. The procedure entailed the use of bilateral
superiorly based unipedicle TRAM flap with more skin
replacement on the right side than on the left (Fig. 8-
31B). The postoperative appearance revealed a discrep-
ancy in the base widths of the reconstructed breasts,
with that on the right larger than that on the left (Fig. 8-
31C). There was also less overall projection of the right
breast than that seen on the left and a slight discrepancy
of the IM folds (Fig. 8-31C).
To address this asymmetry we performed a vertical
mammoplasty procedure on the right TRAM flap (Fig.
8-31D). This resulted in a correction of these differences
in breast shape, projection, and IM fold position, with an
improvement in overall breast symmetry (Fig. 8-31E).
AUGMENTING TRAM FLAP VOLUME
WITH ADJACENT TISSUE
Another option for replacing volume deficits with local
tissue is redistributing the TRAM flap volume or recruit-
ing adipose tissue from adjacent contour, such as the
axilla. Not uncommonly there is excess tissue lateral to
the beast reconstruction in the form of a dog ear from the
original mastectomy flaps (Fig. 8-32E). This tissue can be
mobilized (Fig. 8-32F) on a subcutaneous pedicle and
transferred a short distance to treat a laterally positioned
contour deficit. I learned this technique from John
Bostwick,25 and it has helped in several cases over the
years. This is illustrated in the following case (Fig. 8-
32A–G), in which mobilizing the lower pole and folding
this tissue under the central portion of the TRAM flap,
along with reconstructing the IM fold, was combined with
mobilizing and transferring the excess axillary fat or the
dog ear from the mastectomy procedure to correct a sig-
nificant asymmetry without the use of a synthetic
implant.
COMBINING MULTIPLE
RECONSTRUCTIVE MODALITIES IN
REVISING THE TRULY SUBOPTIMAL
RESULT
This case (Fig. 8-32A–G) demonstrates the additive power
of a number of the previously discussed techniques. At
first glance it would appear that an implant will be neces-
sary for volume symmetry. However, the combination of
mobilizing the flap and folding it beneath itself (Fig.
8-28D), along with reconstructing the IM fold through an
external approach (Fig. 8-32C) (in most cases an internal
approach would be as powerful in reconstructing the
reconstructed breast, i.e., as in Fig. 8-28E) and recruiting
and transpositioning the lateral dog ear (Fig. 8-32E, F),
dramatically changed the appearance of this TRAM
reconstruction from the standpoint of volume, shape, and
symmetry with the opposite breast (Fig. 8-32G).
TREATING BREAST CONTOUR
DEFICITS WITH REDISTRIBUTION
OFTRAM FLAP VOLUME
The Internal Flip-Flop Fat Flap
Most often there is not sufficient volume within the TRAM
flap itself to allow the creation of internal flaps within the

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
397
FIGURE 8-30. A, Postoperative appearance on an AP view following mastectomy for locally recurrent
right breast cancer that required mastectomy and was reconstructed with a split-muscle bipedicle
TRAM flap. B, Note wider base width of TRAM flap reconstruction. The plan for revision includes nip-
ple reconstruction and lipocontouring of inferomedial flap area. C, At surgery we performed a vertical
mastopexy on the TRAM flap to narrow base width and increase projection. D, Postoperatively she
demonstrates better symmetry on the AP view.

398
Reoperative Plastic Surgery of the Breast
FIGURE 8-31. A, Preoperative appearance of patient who is s/p a left modified radical mastectomy
with postoperative radiation therapy for stage II breast cancer. She requires a right mastectomy for a
new right breast cancer and will have a delayed left breast reconstruction with an immediate right
breast reconstruction. B, The preoperative reconstructive plan is outlined for bilateral, superiorly
based, single pedicle TRAM flap reconstructions. C, The postoperative appearance at 3 months demon-
strates an asymmetry of the breasts. The right breast is wider, with more lower pole fullness and with an
upper pole volume deficiency. D, Preoperative plans for revising the right TRAM flap reconstruction
using a vertical mammoplasty technique. This vascularity of the TRAM flap will be maintained from its
superior substance. (continued)

TRAM flap that can be repositioned. The exception to this
is a flap in the somewhat obese patient where the pannus
from the abdomen is of overabundant thickness. In this
situation it is possible to create such an internal adipose
flap, which can be repositioned within the breast.
Dr. Ralph Millard26 was one of the first to describe the
maneuver of elevating and turning over an internal flap of
adipose tissue to treat contour deficits in various areas of
the body. He described this maneuver as the flip-flop fat
flap (Fig. 8-33A–C). As noted, it is usually not feasible to
perform this maneuver in most TRAM flaps. However, in
the flap with significant thickness, specifically when the
TRAM flap may have been horizontally inset, there is
often excessive projection centrally and a deficiency in
vertical height, resulting in a step-off in the superior con-
tour. Such a case is illustrated in this somewhat obese
patient (Fig. 8-34A–F), who underwent reconstruction of
the breast with a surgically delayed TRAM flap. The flap
was horizontally inset, which resulted in suboptimal
upper pole fullness, especially in the superomedial region
of the reconstructed breast (Fig. 8-34A).
In this situation the problem was addressed by elevat-
ing an internal flap of adipose tissue that was superiorly
based, as diagramed on the patient’s skin (Fig. 8-34B). The
flap must be carefully planned so that enough blood sup-
ply is maintained at its base to allow viability once it is
unfurled and transposed. The planning for such a flap
transposition is diagrammed in Figure 8-33A–C.
The patient presented with a deficit in the volume and
indentation of contour in the superomedial aspect of her
reconstructed breast (Fig. 8-34A). Preoperatively, the IM
fold of the reconstructed right breast was higher than that
of the left, so superior transposition of the entire flap was
not an option. Therefore the operative plan included
reconstruction of the defect in the superomedial breast
by the internal flip-flop fat flap and a contralateral
mastopexy (Fig. 8-34B).
The superior inset incision was opened and the supe-
rior breast flap was elevated to the upper limit of the con-
tour deficit in the superomedial area of the reconstructed
breast beyond the limits of the TRAM flap. An incision in
the superior edge of TRAM flap 2 cm below the superficial
surface and a flap of the TRAM flap’s adipose tissue of uni-
form thickness was made parallel to the superficial sur-
face of the flap, dissecting in an inferior direction. Next, a
second flap of adipose tissue based on the inferior and
deep tissue circulation of the TRAM flap was elevated in
the opposite direction by superior dissection such that it
could be turned over (Fig. 8-33C, 8-34C) to fill the volume
deficit in the superomedial aspect of the reconstructed
breast (Fig. 8-34D). The flap was tacked into position with
several PDS sutures (Ethicon, Inc., Somerville, NJ; Fig.
8-34E). The mastopexy with minimal breast tissue reduc-
tion was then performed to match the reconstructed right
breast. A 6-month follow-up demonstrates a significant
improvement in symmetry and in the contour of the right
breast (Fig. 8-34F), seen best in lateral view. It is impor-
tant to realize that this type of reoperative maneuver is
only rarely possible and to emphasize that caution must
be exercised when enacting such a plan to preserve suffi-
cient circulation to this internal flap so as not to produce
fat necrosis.
TREATING BREAST CONTOUR
DEFICITS WITH ADJACENT TISSUE BY
TRANSPOSING THE MUSCLE PEDICLE
OF THE FLAP
In the pedicled TRAM flap breast reconstruction with sub-
optimal projection or contour of the lower pole of the
breast, modest amounts of autologous tissue can be
obtained from below the IM fold in the subxiphoid region.
At times the muscle bulge in this area does not fully atro-
phy. In cases of double muscle or bipedicle flap recon-
struction, this can represent significant volume that may
be available to augment a TRAM flap reconstruction.19 As
mentioned in the Chapter 7, it is often possible to divide
the muscle after 6 months have elapsed.
In situations where there is a volume deficit that has
resulted in decreased breast projection (most often noted
Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
399
FIGURE 8-31. (CONTINUED) E, The postoperative results at
1 year demonstrate more upper pole fullness, a narrower base
width of the breast, and much improved overall symmetry.

400
Reoperative Plastic Surgery of the Breast
FIGURE 8-32. A, Marked breast asymmetry after immediate
left breast reconstruction with single pedicle TRAM flap follow-
ing mastectomy for recurrent breast cancer after previous
lumpectomy and radiation therapy. Note the volume deficiency
and IM fold level discrepancy. B, The initial plan for correction
included an external reconstruction of the IM fold using the
Ryan procedure and placement of an implant beneath the TRAM
flap. C, The Ryan procedure for recreating an IM fold by advanc-
ing and tacking de-epithelialized superior and inferior mastec-
tomy flaps. (continued)
Recreation of IMF from external approach
"The Ryan procedure"
a
De epithelialized
crescent with
full-thickness incision
pectoralis major
lower portion
de-epithelialized
crescent sutured
to periosteum
epithelium
I
M
P
L
A
N
T
c
b
C

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
401
FIGURE 8-32. (CONTINUED) D, Appearance of the lower pole of the breast following mobilization of
inferiorly malpositioned TRAM flap that was folded under the central portion of the TRAM and recre-
ation of a new IM fold at a more superior level. Note residual volume deficit in the superior lateral
aspect of reconstructed left breast (outlined on skin). E, Elevation of lateral dog ear that will be de-
epithelialized and advanced medially by turning it under to fill volume deficit in lateral aspect of supe-
rior pole of the breasts. If there is a large dog ear with sufficient skin this maneuver is possible.
F, De-epithelialized dog ear is mobilized and ready to be transposed medially. G, Improved symmetry
between breasts noted following a combination of maneuvers using autogenous tissue only (i.e., with-
out an implant).

FIGURE 8-34. A, Breast asymmetry with step-off in superomedial contour of TRAM flap in patient
who had a delayed right breast reconstruction. Patient’s adipose layer in the abdomen was very thick.
Note that the IM fold on the side of the reconstruction is already higher than the IM fold on the opposite
breast. B, Preoperative plan for correction (flip-flop flat flap of superior TRAM tissue) outlined on the
skin. (continued)
FIGURE 8-33. A, A diagram of the internal flip-flop fat flap
described by Millard. It may occasionally be helpful in shifting the
internal adipose tissue of the TRAM flap as is seen in this patient
(B). The key is to maintain a sufficient base dimension of the fat
flap to ensure its viability. C, Flap is inset to augment contour.
Internal flip-flop
fat flap
adipose flap to be
elevated
adipose flap elevated
and transposed
contour deformity
corrected
A
B
C

FIGURE 8-34. (CONTINUED) C, Inferiorly based adipose tissue flap raised and made ready to be
turned over into the superomedial contour deficit in the TRAM flap. D, Sutures displaced in the adipose
flap to tack it into position. E, Adipose flap sutured into position. F, Correction of step-off deformity
best seen in lateral view.

and best documented photographically by looking down
on the breasts from above), the volume needed to
autoaugment the breast can be obtained from this divided
muscle pedicle(s). The possibility of producing flap
ischemia in the TRAM flap should be discussed with the
patient preoperatively, but the likelihood of this occurring
is not great.
To carry out this maneuver the inferior breast incision
is opened and the muscle(s) is identified below the subcu-
taneous tissue in the lower aspect of the TRAM flap. The
skin inferior to the IM fold is elevated inferiorly to expose
as much muscle as needed. The dissection is facilitated by
the use of a headlight or a lighted retractor. The muscle
pedicle is transected and raised off of the muscle fascia
layer above the ribs. The inferior pole of the TRAM flap is
also elevated to create a space into which to place the
muscle pedicle. The muscle pedicle itself usually has an
excellent retrograde blood supply. The rectus muscle vol-
ume is most appropriately placed to correct inferomedial
volume deficiencies or deficiencies of central projection in
the TRAM flap (Fig. 8-35A–D). The IM fold is then re-
established by retacking the subcutaneous tissue to the
musculofascial layer. As previously noted, the TRAM flap
breast mound does not suffer from the late division of the
pedicle (although caution should be exercised in previ-
ously radiated beds).
RECONSTRUCTING CONTOUR
DEFECTS WITH AUTOLOGOUS FAT
GRAFTS
A simple method to improve or correct small or moderate
contour deficits is autologous fat injection.27 The use of
this method to treat small contour deficits is exactly like
that described in Chapters 6 and 9. It requires the harvest
of fat cells from a distant site, such as the lower abdomen,
lateral thigh, posterior hip, or knee, using standard lipo-
suction instrumentation. Most often a cannula of 3.0 to
3.7 mm is used. It is important to inject the fat donor area
with a solution containing lidocaine and epinephrine to
achieve vasoconstriction. This will permit a harvest of
adipose cells with minimal admixed blood. I prefer to use
0.25% lidocaine and concentrations of epinephrine
between 1:400,000 and 1:1,000,000 per cc. It is important
to wait for blanching of the overlying skin to occur before
harvesting adipose tissue. The fat is then aspirated using a
syringe aspiration system and is placed into 10-cc
syringes and allowed to stand. The infranatant fluid is
drained and the remainder of the oils can be removed by a
simple wick application to the adipose tissue. The fat may
also be centrifuged at 3000 rpm for 5 minutes as
described by Coleman.26 The limits of the contour deficit
to be corrected are outlined on the skin of the recon-
structed breast with a marking pen. This area is also
injected with a solution of local anesthetic containing
lidocaine and epinephrine, again waiting until there is
good vasoconstriction in the recipient bed as evidenced
by blanching of the overlying skin. The adipose tissue is
then injected in strands at multiple levels of the tissue in
the recipient bed using a 14-gauge needle. It is important
to layer these strands into the defect and not inject the fat
as a clump or ball. The fat aspirate is injected into all lay-
ers of the contour deficiency, including the muscle, and
into the subcutaneous space. Depending on the degree of
the contour deficit, several injections at multiple opera-
tive settings may be necessary. Injected fat tissue grafts
have been documented in the medical literature over
many decades to be notorious for their difficulty taking or
surviving. Therefore the need for several treatments must
be explained to the patient preoperatively, along with the
fact that these fat grafts have a tendency to resorb with
time. It is not uncommon to lose between 30% and 50% of
404
Reoperative Plastic Surgery of the Breast
FIGURE 8-35. A, Patient who had single pedicle TRAM flap
reconstruction with inadequate projection of lower pole of
TRAM flap. B, Skin flaps elevated to explore rectus muscle at
inferior aspect of the TRAM flap. C, Rectus muscle is transected
and folded under adipose portion of flap to increase lower pole
projection, similar to maneuver described in Figure 8-28D. D,
Increased projection of lower aspect of TRAM flap by autoaug-
mentation with rectus muscle pedicle.
A
B
C
D
flap elevated
and lower part
folded under

the initial correction. Nevertheless, such grafts are valu-
able for correcting small deficits of contour, and they may
be redone within 6 months of the initial procedure. The
following patient illustrates the combined use of flap
reorientation, skin envelope modification, and autolo-
gous fat graft injection to treat contour deficits after
TRAM flap breast reconstruction.
In addition to autologous fat cell grafting by injection,
small contour deficits may be corrected by the placement
of dermis–fat grafts.28 These are small composites of adi-
pose tissue with overlying dermis that has been harvested
from a distant site where there is an excess of skin and
adipose tissue. This is most commonly noted in the lat-
eral-most extent of the IM incision, where a small dog ear
is often present. The epidermal layer is removed in a stan-
dard de-epithelialization maneuver. The grafts can be
implanted beneath the skin overlying an area of contour
deficit. Here again it is important to harvest the grafts in
an atraumatic manner and to achieve anesthesia and
vasoconstriction in the recipient area with the use of an
injection of local anesthetic containing epinephrine. The
contour deformity is carefully marked on the overlying
skin before surgery. A precise pocket is created by careful
dissection beneath the contour deficit to accept the graft.
Hemostasis in this pocket must be perfect. The graft is
then inserted with the dermis side oriented superiorly.
Generally it is not necessary to fix the graft in the pocket
with sutures.
FAT NECROSIS
Fat necrosis is the most common complication of TRAM
flap breast reconstruction.1 It is a process that results
from the trauma of surgical dissection and some degree of
ischemia in the adipose tissue of the TRAM flap that is
being transferred.
The circulatory dynamics of the adipose tissue layers of
the lower abdominal wall were discussed in Chapter 7,
and the importance of appropriate flap selection was
emphasized. I have found that strict adherence to the
guidelines discussed and the almost routine use of prelim-
inary surgical delay procedure in unipedicle TRAM flap
reconstruction have significantly reduced the incidence of
fat necrosis in my patients. Nevertheless, the fat necrosis
rate is not zero. In my experience approximately 10% of
my patients undergoing unipedicle flap reconstruction
exhibit some degree of fat necrosis.
I believe that fat necrosis usually does not require sur-
gical intervention. Most often it is a localized area of firm-
ness in the reconstructed breast that will soften over time.
The problem is more likely to occur in the deeper or sub-
scarpal adipose layer in the zones of the flap that are adja-
cent to the muscle pedicle (zones II and III). For this
reason I believe that it is generally a good strategy to
resect the adipose tissue deep to Scarpa fascia in these tis-
sue zones if the volume requirements can be satisfied with
the other adipose tissue in the TRAM flap. When fat
necrosis is noted following TRAM flap breast reconstruc-
tion, it is very important to point out these areas of firm-
ness to the patient as soon as they are noted in the
postoperative period and to reassure the patient about the
nature of the firmness. As noted earlier, most of the
smaller areas and cases in which there is a moderate firm-
ness of the tissue will improve with the passage of time. It
is my experience that this will most often take about 1
year. At that point, there will usually be no firm areas in
the breast. However, if the area of fat necrosis is more
extensive or very firm to hard in nature, most likely it will
not soften. Occasionally it will be visible and rarely will it
be uncomfortable, especially when the patient lies on it. In
this case it may be necessary to establish the diagnosis by
needle aspiration cytology examination, and if the patient
desires its excision revisional surgery can be done.
The following patient illustrates the typical presenta-
tion of fat necrosis after a TRAM flap breast reconstruc-
tion. This 55-year-old patient had undergone a left
mastectomy and desired reconstruction with her own tis-
sue (Fig. 8-36A). The plan was for a single pedicle nonde-
layed TRAM flap and a contralateral breast reduction. The
outcome at 6 weeks is seen (Fig. 8-36B). Unfortunately,
transmidline tissue (zone II) was placed in the IM fold dur-
ing a vertical inset of this flap. She presented with a mass
in the center of the IM fold, along with poor definition of
the IM fold, which was lower than that of the opposite
breast, and excess volume in the upper aspect of the TRAM
flap (Fig. 8-36C). The plan was to excise the fat necrosis
and reconstruct a more well-defined IM fold (Fig. 8-36C).
At surgery there was a localized area of fat necrosis in the
deep adipose layer (or subscarpal fat layer; Fig. 8-36D).
This was excised without difficulty (Fig. 8-36E). The
revision, nipple reconstruction, and subsequent intrader-
mal tattoo produced very satisfactory symmetry for this
patient (see Fig. 8-36F).
As noted, fat necrosis most often occurs due to inap-
propriate procedure selection, i.e., relying on the circula-
tion in a superiorly based unipedicle flap to provide
circulation to more than two zones of tissue.
A more dramatic example of such a situation is noted
in the following case (Fig. 8-37A–E), in which this patient
with very large breasts preoperatively underwent immedi-
ate postmastectomy reconstruction of the left breast with
an undelayed unipedicle flap. This immediate reconstruc-
tion was done for local recurrence following a previous
lumpectomy and radiation therapy (Fig. 8-37A). The
transmidline adipose tissue (zone II) was positioned in the
medial aspect of her reconstruction. She developed a large
area of hardness in the medial aspect of her reconstructed
breast (Fig. 8-37B). An analysis of her appearance
revealed that her reconstructed breast was considerably
Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
405

larger than the opposite breast and therefore some of the
fat necrosis problem may have been avoided by appropri-
ately downsizing her TRAM flap at the time of the recon-
struction.
This patient’s revisional surgery entailed opening her
inset incisions and resecting the hard area of fat necrosis
(Fig. 8-37C,D). We then performed a mobilization of her
entire TRAM flap and medially translocated the flap to
restore the medial fullness in the reconstructed breast
(Fig. 8-37B). We then reduced the size of her skin paddle
and tailored the skin envelope to optimize the aesthetics
of the reconstructed breast mound. This produced a soft
breast mound with improved symmetry when compared
with the opposite breast (Fig. 8-36E).
406
Reoperative Plastic Surgery of the Breast
FIGURE 8-36. A, Patient with left postmastectomy defect who
is seen before planned reconstruction with superiorly based sin-
gle pedicled TRAM flap. B, Appearance of left breast reconstruc-
tion with concomitant right breast reduction. Patient had a large
area of fat necrosis in the reconstructed left breast in the mid-
portion of the inferior onset of the flap. C, The surgical plan is
for revision with reconstruction of the IM fold, excision of fat
necrosis, and reduction of upper flap volume by liposuction.
(continued)

FLAP LOSS FOLLOWING TRAM FLAP
RECONSTRUCTION
Major flap loss following TRAM flap breast reconstruc-
tion is, fortunately, an uncommon problem. Such losses
do occasionally occur, however, and they can manifest
themselves as extensive fat necrosis with an intact overly-
ing skin envelope or, more commonly, there is a signifi-
cant loss of both skin and adipose tissue in the TRAM flap
resulting in a significant breast asymmetry. Total flap loss
is rare, and when it occurs it is most likely the result of a
failed free flap breast reconstruction. As noted previously,
the surgeon needs to carefully evaluate every breast recon-
struction following surgery and be especially keyed in on
those reconstructions that show signs of potential
ischemia. Skin suture removal to relieve tension on the
closure and flap re-exploration are possible treatment
options. It is wise to take an aggressive approach of treat-
ing such flaps with early resection of nonviable tissue and
wound closure. This will avoid a prolonged period of addi-
tional dressing changes and diminish the likelihood of
extensive scarring.
Treatment of significant flap loss usually entails the
provision of additional flap tissue for salvage of the
breast reconstruction. The most commonly employed
reconstructive option is regional pedicle flaps, most often
using the ipsilateral latissimus dorsi musculocutaneous
flap29 or the scapular or parascapular flap.30 An addi-
tional option is free tissue transfer, generally from the
contralateral latissimus dorsi flap, the scapular flap, or
the gluteus maximus flap.31 Additionally, use of the gra-
cilis musculocutaneous flap32; the lateral thigh flap33; and
the Rubens,34 or deep circumflex iliac artery flap,35 have
been reported.
Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
407
FIGURE 8-36. (CONTINUED) D, Fat necrosis in lower pole of
breast reconstruction seen in the deep (subscarpal) layer of adi-
pose tissue in the TRAM flap. E, The well-circumscribed area of
fat necrosis is resected. F, One year later a better IM fold by
internal suture has been established and good symmetry results
from this and NAC reconstruction with an infradermal tattoo.

408
Reoperative Plastic Surgery of the Breast
FIGURE 8-37. A, Plan for immediate breast reconstruction using single muscle TRAM flap designed
to carry 2.5 zones of tissue. B, A large area of fat necrosis developed medially in the reconstructed left
breast causing discomfort for the patient. The plan for revisional surgery procedure includes resection
of fat necrosis and medial mobilization of entire TRAM flap to reduce the size of the reconstructed
breast. C, The area of fat necrosis is dissected free from the surrounding TRAM flap tissue. D, The fat
necrotic TRAM tissue is excised. (continued)

The ipsilateral latissimus dorsi musculocutaneous flap
is by far the most commonly used flap for salvage of a
severely compromised TRAM flap breast reconstruction.
This flap is one that is familiar to virtually all reconstruc-
tive surgeons. It includes a highly reliable skin paddle that
can be positioned almost anywhere on the muscle. This
permits exact replacement of skin deficits at various loca-
tions on the compromised TRAM flap. This musculocuta-
neous flap has a vascular pedicle that is not only of good
caliber but also of substantial length. This permits an
excellent arc of rotation and increases the flexibility and
utility of this musculocutaneous flap for salvaging a sub-
optimal breast reconstruction.
In performing flap elevation, it is my preference to
include both the thoracodorsal pedicle and the serratus
collateral vessels whenever possible. The blood flow in the
serratus branch may be sufficient to carry the entire mus-
culocutaneous flap in the event that the thoracodorsal
pedicle has been sacrificed. However, I have observed that
often the distal aspect of the skin paddle is compromised
in this situation. When evaluating a patient preopera-
tively, the surgeon must check the contractility of the latis-
simus dorsi muscle. If the nerve supply to the latissimus is
intact, then in most cases the vascular pedicle will also be
intact.
When a breast reconstruction with a free microvascu-
lar TRAM flap is performed, the most common recipient
is the thoracodorsal artery and vein. I believe it is impor-
tant to perform the anastomosis proximal to the take-off
of the serratus collateral branch. This is done to preserve
the blood supply through this branch to the latissimus
dorsi so that this musculocutaneous flap may be used as a
salvage procedure in the rare event that the free tissue
transfer is unsuccessful.
The latissimus dorsi musculocutaneous flap was ini-
tially described by Tansini in 1906. It lay dormant in the
medical literature until the mid 1970s, when the latis-
simus flap became the most used musculocutaneous flap
for breast reconstruction. The point of rotation of the flap
is determined by the position of the vascular pedicle,
which is 8 to 10 cm below the axillary artery. When trans-
posing the flap to the chest for breast reconstruction, the
surgeon must pass it through a high axillary tunnel29 to
preserve an optimal lateral breast contour.
Knowing the position of the vascular pedicle and estab-
lishing this as the point of rotation, the surgeon can con-
struct a template of paper or cloth. The template consists
of both muscle, which tapers markedly toward its tendi-
nous insertion of the humerus, and the skin paddle and
will serve as an accurate guide for transpositioning the
flap to the chest area. As noted, the pedicled ipsilateral
latissimus dorsi musculocutaneous flap is especially use-
ful for laterally positioned defects. As previously men-
tioned, the most well-perfused portion of the TRAM flap
should be positioned superiorly and medially whenever
possible. This will ensure the best chance for preservation
of the medial contour in the reconstructed breast, even in
the event that some circulatory compromise in the TRAM
flap occurs laterally. Tissue losses in such a situation most
often will be located laterally. Reconstruction of losses in
the lateral aspect of a breast flap is easily amenable to
treatment with the transposed latissimus dorsi flap.
Although the latissimus flap can be used to reach the
parasternal region quite readily when the tendon of inser-
tion is released, the surgeon must tunnel through the
existing TRAM flap, which may present additional diffi-
culties in terms of producing fat necrosis and, addition-
ally, abnormal contours in the reconstructed breast.
Salvage of a major flap loss after TRAM flap breast
reconstruction is illustrated by the following case (Fig. 8-
38A–M). The TRAM flap proved to be a poor choice in this
significantly obese patient (Fig. 8-38C). She sustained
extensive flap loss despite the use of a split-muscle bipedi-
cle flap (Fig. 8-38C). Tissue compromise occurred both
medially and laterally. This resulted in open wounds at
both locations, a marked loss of flap tissue, and volume
deficits and contour abnormalities in both the medial and
lateral aspects of the flap. The open wounds in these loca-
tions were accompanied by marked loss of flap tissue.
Serial débridements resulted in severe contour deficits
both medially and laterally in the reconstructed breast
(Fig. 8-38D). After complete healing of the wounds and
scar maturation, the suboptimal reconstructive result was
salvaged by resecting the scar tissue, with the plan being to
recreate the defect (Fig. 8-38D). The remaining TRAM flap
Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
409
FIGURE 8-37. (CONTINUED) E, The appearance of the breast
reconstruction following medial transposition of the TRAM flap
and reconstruction of the NAC.

tissue was mobilized along with its underlying muscle
pedicles by elevating the skin, fat, and muscle of the flap as
one unit. This flap remnant was translocated medially
(Fig. 8-38f). A large lateral tissue deficit was envisioned
(Fig. 8-38E). With the use of a skin template the lateral
defect of skin in subcutaneous adipose tissue was carefully
reconstructed by positioning the skin paddle on the latis-
simus in the precise location (Fig. 8-38G). The flap was ele-
vated (Fig. 8-38H), transposed, and inset to the lateral
defect (Fig. 8-38I). The patient demonstrated a restoration
of excellent breast contour, and the latissimus flap pro-
duced good symmetry with the opposite breast from the
standpoint of volume restoration. Primary wound healing
followed, and the patient recovered well (Fig. 8-38J,K).
Subsequently, the patient underwent nipple areola recon-
struction (Fig. 8-38L,M) and reconstruction of the
abdomen as finishing touches on her breast reconstruc-
tion.
As previously mentioned, medial flap loss with the obli-
gate scarring produces a deformity that is difficult to
reconstruct. The only hope of establishing a good breast
contour is to resect the scar tissue and recreate the defect,
and then replace the tissue deficit with vascularized flap
tissue. Potential strategies include mobilizing the TRAM
tissue and translocating it medially, if enough excess flap
is present laterally. Alternatively, the surgeon may be
forced to directly replace the medial tissue deficit by pro-
viding a new and additional flap. Most often the latter
reconstructive plan is followed. In this situation free tis-
sue transfer becomes the modality of choice.
Donor flap options include the scapular, parascapular,
gluteus maximus, gracilis musculocutaneous, posterior
thigh or gluteal thigh flap, and the Rubens flap described
by Elliot and Hartrampf.34 The surgeon must carefully
analyze the prospective flap donor sites for the amount
and distribution of adipose tissue available and consider
410
Reoperative Plastic Surgery of the Breast
FIGURE 8-38. A, Preoperative AP view of patient requesting right breast reconstruction with TRAM
flap. B, Oblique view demonstrating protuberance and obesity of abdomen. (continued)

FIGURE 8-38. (CONTINUED) C, The plan for right breast
reconstruction with split-muscle bipedicle TRAM is outlined. D,
Significant tissue loss noted medially and laterally with scarring
and abnormal contour. E, Revision will include resection of
medial and lateral scarred areas and medial transposition of
remaining TRAM flap remnant.

412
Reoperative Plastic Surgery of the Breast
FIGURE 8-38. (CONTINUED) F, Intraoperative view following resection of lateral scar and medial
transposition of TRAM. G, Outline of latissimus dorsi musculocutaneous flap that will be used to recon-
struct. H, The lateral defect resulting from TRAM flap repositioning. I, Latissimus flap elevated and
about to be transposed through a high axillary tunnel. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
413
FIGURE 8-38. (CONTINUED) J, Intraoperative appearance of latissimus flap following lat-
eral inset. K, Plan for revision of breast reconstruction includes NAC reconstruction and lipo-
suction of abdomen. L, Lateral preoperative view. M, Following revision a very satisfactory
symmetry is noted on AP and lateral views.

the prospects for concealing scars related to flap harvest
and transfer. The internal mammary artery and vein are
readily available as recipient vessels for these flaps when
defects in the medial breast region are to be recon-
structed. This vascular pedicle can be readily accessed in
the bed of the third and fourth costal cartilage. In this sit-
uation it is very often necessary to extend the excisions on
the breast mound medially to allow access to and prepara-
tion of this recipient pedicle for a microvascular anasto-
mosis. The artery is of consistent caliber, but the vein can
be somewhat thin, delicate, and at times friable.
As mentioned, total flap loss is exceedingly rare with
pedicle TRAM flap breast reconstruction. I evaluated one
patient who sustained complete flap loss after pedicle flap
transfer. Flap loss after free flap reconstruction is more
likely but still uncommon, with flap loss rates ranging
from 2% to 5% in most series. The gluteus maximus mus-
culocutaneous flap and the Rubens flap34,35 appear to be
the flaps of choice for salvaging this situation. The con-
tralateral latissimus dorsi muscle is available in the event
that the pedicle to the ipsilateral latissimus has been dam-
aged or where the previous free flap procedure has made
this pedicle unusable.
Once again, it is important to carefully estimate the
tissue requirements for such a salvage procedure before
surgery. This will allow the selection of the appropriate
flap donor site for the particular reconstructive effort. It is
my experience that the flap tissue provided by the gluteus
maximus muscle is not as malleable as the TRAM flap tis-
sues. The donor area can show a definite contour differ-
ence when compared with the opposite buttock, and a
lengthy scar results from its use. The flap can be trans-
ferred on either the superior gluteal artery or the inferior
gluteal artery. When dissecting the latter, it is important to
avoid injury to the inferior gluteal nerve. An example of a
patient who sustained a total TRAM flap loss and whose
reconstruction was salvaged with a fee gluteus maximus
flap is depicted (Fig. 8-39A–I). The lateral thigh flap,
which is based on the lateral femoral circumflex vessel, is
another potential source for flap donor tissue. The dissec-
tion removes tissue in the lateral thigh area at the per-
itrochanteric region. This too can result in a local contour
deficit. The pedicle is quite lengthy and of sufficient cross-
sectional diameter to nicely match the thoracodorsal or
internal mammary vessels. Because of the donor site
deformity the lateral thigh flap is a flap of last resort in my
practice.
TRAM FLAP DONOR SITE PROBLEMS
The abdominal wall defect following TRAM flap harvest
must be carefully closed by reapproximating the medial
fascial layer to two layers of lateral fascia36 (Fig. 8-40).
Despite all of the innovations and significant attention to
detail in the abdominal wall closure after TRAM flap
breast reconstruction, the hernia rate, although much
lower, has not been reduced to zero.1,37 Additional factors
involved in the genesis of such hernias may be progressive
postoperative attenuation of the abdominal wall tissue,
414
Reoperative Plastic Surgery of the Breast
FIGURE 8-39. TRAM flap donor site requires closure of two layers of fascia laterally, the oblique fas-
cia and rectus fascia, which are sewn to the rectus abdominis fascia and linea alba. A, Complete TRAM
flap loss after attempted right breast reduction. B, Oblique view of breast area with scarred skin and
absent breast. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
415
FIGURE 8-39. (CONTINUED) C, Salvage reconstruction of right breast planned using gluteus max-
imus musculocutaneous flap. D, Gluteus maximus free flap harvested and ready for transfer. E,
Appearance of right breast following salvage reconstruction with gluteus maximus free flap (AP view).
F, Lateral view of breasts demonstrates satisfactory symmetry in terms of volume and projection.

416
Reoperative Plastic Surgery of the Breast
interruption of the intercostal nerve supply to the rectus
muscle remnants resulting in muscle imbalance, and
other postoperative complications producing significant
stress in the abdominal wall repair such as forceful
emphasis and pulmonary complications associated with
significant emesis following surgery.
Abdominal wall hernia repair after TRAM flap breast
reconstruction has classically taken the form of attempt-
ing to reapproximate the abdominal wall fascia36 with or
without the onlay (Fig. 8-41) of synthetic mesh material
placed to reinforce the fascial repair. This method can be
successful in many patients. Nevertheless, the reconstruc-
tive surgeon will encounter cases of significant abdominal
wall bulging with a large area of tissue attenuation or be
confronted with a hernia that has occurred or even
recurred after an initial attempt at surgical correction
using the technique in which the abdominal wall repair is
reinforced with an onlay of synthetic mesh.
Over the past 5 years I have treated more than 20
patients who have presented with large, often painful,
bulges in the lower abdominal region after TRAM flap
breast reconstruction. Each of the patients was treated
with abdominal wall exploration that included opening
the weakened abdominal wall tissues by performing an
exploratory laparotomy. This approach permits the place-
ment of a large piece of reinforcing synthetic mesh mate-
rial in an intraperitoneal location, with the mesh applied
to the inner aspect of the parietal peritoneum on all sides
of the defect in the lower abdominal wall. The omentum is
then tacked over this mesh to isolate it from potential con-
tact with the abdominal viscera. Using this technique I
have been uniformly successful in correcting the defects
in all of these patients. It is my technique of choice37 for
treating large defects and bulges in the lower abdomen
following TRAM flap breast reconstruction.
Routinely, a patient who has sustained a hernia is care-
fully assessed preoperatively to determine the location
and size of the defect (Fig. 8-42A). This is done with the
patient in a standing position. The exact dimensions of the
bulge are then marked by placing dots on the patient’s
skin with a marking pen (Fig. 8-42B). As previously noted,
there is most often a large area of attenuation of the lower
abdominal wall musculature extending beyond the center
of the most prominent portion of the bulge. After the
dimensions are marked the patient is taken to surgery,
where the operation is performed using general endotra-
cheal anesthesia. The technique includes reopening the
lower abdominal incision and elevating the skin flap usu-
ally to the level of the umbilicus or slightly beyond. It is
often necessary to take down the umbilical stock. In this
way the defect in the abdominal wall fascia is usually eas-
ily identified. To confirm the dimensions of the defect, a
request is made of the anesthesiologist to provide a forced
Valsalva maneuver with a sustained positive pressure ven-
tilation delivered through the endotracheal tube (Fig. 8-
42C). This is helpful in demonstrating the precise extent
of the abdominal wall defect. The defect dimension is
inscribed on the abdominal wall tissues using methylene
blue (Fig. 8-42C).
A vertical incision in the attenuated abdominal fascial
tissues is then created, allowing exposure of the abdominal
contents. Inspection is immediately made for any intra-
abdominal pathology and careful evaluation of the omen-
tum is carried out. This is done to specifically note its size
and the ability to bring it down to cover the intended mesh
repair. Most often a 10 × 10–inch sheet of sterile Prolene
mesh that has been soaked in antibiotic solution is used. It
is brought to the field and trimmed so that dimensions are
larger than the hernia by approximately 4 cm on all sides
of the defect (Fig. 8-42D). The mesh is then sewn onto the
onlay mesh
unfavorable tension
stress
FIGURE 8-40. The application of synthetic mesh to abdominal
wall following TRAM flap harvest. Mesh must absorb and negate
a significant tension stress.
FIGURE 8-41. Intraperitoneal placement allows mesh to
absorb significant tension stress and convert it to a compression
stress.

FIGURE 8-42. A, Patient who underwent left breast reconstruction using contralateral (right) rectus
muscle TRAM flap presents with 2-time recurrent hernia. B, Area of fascial attenuation noted with the
patient upright extends beyond the midline. C, Intraoperatively the area of fascial attenuation is out-
lined. Note that it extends significantly superiorly and laterally. D, Planned intraperitoneal placement of
Prolene mesh, which will be fixed to abdominal wall tissues on all sides of the defect. E, Intraoperative
view showing mesh being tacked into position with multiple mattress sutures through the entire wall
musculature peripheral to the defect. (continued)
intraperitoneal mesh
B

418
Reoperative Plastic Surgery of the Breast
parietal peritoneum surface of the abdominal wall using
full-thickness suture placement through the abdominal
wall (Fig. 8-42E). Beginning externally, the needle is
passed through the entire thickness of the abdominal wall
musculature (Fig. 8-42E). After catching the intraperi-
toneal mesh, the suture is then brought out through the
abdominal musculature in a vertical mattress stitch tech-
nique. The mesh is first applied from the region superior to
the defect then brought to the areas lateral and, finally,
inferior to the defect. With the anesthesiologist providing
maximum muscle relaxation, the mesh is placed with a sig-
nificant amount of tightness to make the defect smaller.
This improves the relationships of the abdominal wall
musculature as the fascial defects become smaller. This
maneuver also often causes bunching of the tissue of the
attenuated hernia on the surface of the abdominal wall. It
then allows much of this tissue to be excised.
In all cases it is most often possible to achieve an edge
to edge closure of the abdominal wall fascia. This allows
complete coverage of the intraperitoneal inclusion of the
synthetic mesh. Before the final sutures are placed, the
omentum is brought down to the inferior-most aspect of
the defect and tacked to the mesh. In this way the mesh is
excluded from having contact with the abdominal viscera.
FIGURE 8-42. (CONTINUED) F, The recalicitrant abdominal bulge in the patient in this operative
sequence is as pictured on the AP view. G, Postoperative appearance of patient following hernia repair.
Note restoration of normal lower abnormal contour. H, Note restoration of normal lower abdominal
contour with correction of the bulge.

Once the external fascial tissues are closed over the
mesh, two suction drains are placed and closure of the
abdominal wound proceeds in standard fashion with the
inferior advancement of the skin flap and repositioning
of the umbilical stalk. Improved abdominal contours are
noted immediately postoperatively after such a repair of
these defects (Fig. 8-42H). Patients will have some ele-
ment of discomfort related to tightening of the muscle.
Generally an overnight stay in the hospital is required.
Suction drains remain in place usually for 5 to 7 days.
Recurrence of the laxity and bulges has been extremely
rare.
In some way this method of intraperitoneal mesh appli-
cation provides a means of re-establishing normal
anatomic relationships of the abdominal wall musculature.
I find it helpful in many patients who present with bulges
after TRAM flap breast reconstruction. It is especially help-
ful in patients with recurrent hernias.
REFERENCES
1. Watterson PA, Bostwick J III, Hester TR Jr, et al. TRAM flap
anatomy correlated with a 10-year clinical experience with
556 patients. Plast Reconstr Surg. June 1995 95(7) 1185–1194.
2. Schusterman MA, Kroll SS, Miller MJ, et al. The free trans-
verse rectus abdominis musculocutaneous flap for breast
reconstruction: one center’s experience with 211 consecutive
cases. Ann Plast Surg. March 1994;32(3):234–241; discussion
241–242.
3. Alderman AK, Wilkins EG, Kim HM, et al. Complications in
postmastectomy breast reconstruction: two-year results of
the Michigan Breast Reconstruction Outcome Study. Plast
Reconstr Surg. June 2002;109(7):2265–2274.
4. Hultman CS, Daiza S. Skin-sparing mastectomy flap compli-
cations after breast reconstruction: review of incidence, man-
agement, and outcome. Ann Plast Surg. March 2003;50(3):
249–255; discussion 255.
5. Chang DW, Reece GP, Wang B, et al. Effect of smoking on
complications in patients undergoing free TRAM flap breast
reconstruction. Plast Reconstr Surg. June 2000;105(7):
2374–2380.
6. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific
rationale for tobacco abstention with plastic surgery. Plast
Reconstr Surg. September 15, 2001;108(4):1063–1073; dis-
cussion 1074–1077.
7. Padubidri AN, Yetman R, Browne E, et al. Complications
of postmastectomy breast reconstructions in smokers, ex-
smokers, and nonsmokers. Plast Reconstr Surg. February
2001;107(2):342–349; discussion 350–351.
8. Takeishi M, Shaw WW, Ahn CY, et al. TRAM flaps in patients
with abdominal scars. Plast Reconstr Surg. March 1997;
99(3):713–722.
9. Myers MB, Cherry G. Use of vital dyes in the evaluation of the
blood supply of the colon. Surg Gynecol Obstet. January
1969;128(1):97–102.
10. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk
after skin-sparing and conventional mastectomy: a 6-year fol-
low-up. Plast Reconstr Surg. August 1999;104(2):421–425.
11. Pinedo HM. Thrombosis, prevalence and new evidence on
current perceptions of risk. Cancer Treat Rev. June 2003;
29(suppl 2):3–5.
12. DVT treatment.
13. Pollock H, Pollock T. Progressive tension sutures: a technique
to reduce local complications in abdominoplasty. Plast
Reconstr Surg. June 2000;105(7):2583–2586; discussion
2587–2588.
14. Seroma catheter. Greer Medical Inc., Santa Barbara, Calif.
15. Bilgen IG, Ustun EE, Memis A. Fat necrosis of the breast:
clinical, mammographic and sonographic features. Eur J
Radiol. August 2001;39(2):92–99.
16. Kroll SS. Fat necrosis in free transverse rectus abdominis
myocutaneous and deep inferior epigastric perforator flaps.
Plast Reconstr Surg. September 2000;106(3):576–583.
17. Matarasso A. Suction mammaplasty: the use of suction lipec-
tomy alone to reduce large breasts. Clin Plast Surg. July
2002;29(3):433–443.
18. Restifo RJ. Secondary use of the rectus muscle pedicle for
TRAM flap volume deficiencies. Ann Plast Surg. April
1998;40(4):343–348.
19. McCraw JB, Maxwell GP. Early and late capsular “deforma-
tion” as a cause of unsatisfactory results in the latissimus
dorsi breast reconstruction. Clin Plast Surg.
October
1988;15(4):717–726.
20. Fagrell D, Berggren A, Tarpila E. Capsular contracture
around saline-filled fine textured and smooth mammary
implants: a prospective 7.5-year follow-up. Plast Reconstr
Surg. December 2001;108(7):2108–2112; discussion 2113.
21. Thorne CH, Beasley RW, Sherrell JA, et al. Grabb and Smith’s
Plastic Surgery. Philadelphia, Pa: Lippincott Williams &
Wilkins; 2006.
22. Lassus C. A 30-year experience with vertical mammaplasty.
Plast Reconstr Surg. February 1996;97(2):373–380.
23. Lejour M. Vertical mammaplasty: update and appraisal of
late
results.
Plast
Reconstr
Surg.
September
1999;104(3):771–781; discussion 782–784.
24. Bostwick J III Aesthetic and Reconstructive Breast Surgery. St.
Louis, Mo: Mosby; 1983.
25. Millard DR. The Principalization of Plastic Surgery. Boston,
Mass: Little, Brown and Co; 1986.
26. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast
Surg. January 2001;28(1):111–119.
27. Mackay DR, Manders EK, Saggers GC, et al. The fate of der-
mal
and
dermal-fat
grafts.
Ann
Plast
Surg.
July
1993l;31(1):42–46.
28. Bostwick J III. Latissimus dorsi flap: current applications.
Ann Plast Surg. November 1982;9(5):377–380.
29. Siebert JW, Longaker MT, Angrigiani C. The inframammary
extended circumflex scapular flap: an aesthetic improvement
of the parascapular flap. Plast Reconstr Surg. January
1997;99(1):70–77.
30. Shaw WW. Superior gluteal free flap breast reconstruction.
Clin Plast Surg. April 1998;25(2):267–274.
31. Yousif NJ. The transverse gracilis musculocutaneous flap.
Ann Plast Surg. October 1993;31(4):382.
32. Elliott LF, Beegle PH, Hartrampf CR Jr. The lateral transverse
thigh free flap: an alternative for autogenous-tissue breast
reconstruction. Plast Reconstr Surg. February 1990;85(2):
169–178; discussion 179–181.
33. Hartrampf CR Jr, Noel RT, Drazan L, et al. Ruben’s fat pad for
breast reconstruction: a periiliac soft-tissue free flap. Plast
Reconstr Surg. February 1994;93(2):402–407.
34. Elliott LF, Hartrampf CR Jr. The Rubens flap. The deep cir-
cumflex iliac artery flap. Clin Plast Surg. April 1998;25(2):
283–291.
35. Kroll SS, Marchi M. Comparison of strategies for preventing
abdominal-wall weakness after TRAM flap breast reconstruc-
tion. Plast Reconstr Surg. June 1992;89(6):1045–1051; discus-
sion 1052–1053.
36. Shestak KC, Fedele GM, Restifo RJ. Treatment of difficult
TRAM flap hernias using intraperitoneal synthetic mesh
application. Plast Reconstr Surg. January 2001;107(1):55–62;
discussion 63–66.
37. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic
contouring of the abdomen following TRAM flap breast
reconstruction by the use of polypropylene mesh. Plast
Reconstr Surg. November 1995;96(6):1346–1350.
Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
419

420
C h a p t e r 9
C h a p t e r 9
◗Reoperative Surgery Following
Lumpectomy and Radiation Therapy
Plastic Surgery Reconstruction of the
Lumpectomy Defect 425
Reconstruction of Entire Breast Following
Completion Mastectomy 425
The Postlumpectomy Defect 425
Scars Following Lumpectomy 429
Breast Asymmetry Following Lumpectomy and
Radiation Therapy 429
Correction of Small Contour Deficits—Tissue
Shifts 429
Autologous Fat Transplantation for Contour
Correction 432
Use of Combined Dermis–Fat Grafts and
Autologous Fat Injection for Larger Deficits in
the Nonradiated Patient 433
The Postlumpectomy plus Radiation Deformity
435
Contour Abnormalities Treated with Implants 436
Surgical Modification of the Opposite Breast
Following Lumpectomy and Radiation
Therapy 440
Surgical Modification of Both Breasts Following
Lumpectomy and Radiation Therapy 442
Oncoplastic Surgical Treatment for the Post-
Lumpectomy Patient 442
Reconstruction of Postlumpectomy Defects with
Flaps 445
Reconstruction of the Partial Mastectomy Defect
with Autogenous Tissue 446
Closing Thoughts 449
References 454
Breast-conserving therapy is currently the most common
method of treating patients with breast cancer. The effi-
ciency and validity of such treatment have been estab-
lished by many large prospective studies [National
Surgical Adjuvant Breast and Bowel Project (NSABP) and
World Health Organization (WHO)] that have identified
the equivalence of survival in patients so treated when
compared with those treated with standard modified radi-
cal mastectomy.1–3 The treatment entails removing a breast
cancer with a surrounding rim of normal breast tissue
with the subsequent provision of adjuvant radiation to the
remaining breast parenchyma. This treatment preserves
most of the patient’s breast while accomplishing resection
and local control of the patient’s breast cancer. This breast-
conserving treatment carries with it a 1% per year risk of
local recurrence, but the survival rates of patients treated
in this way are equivalent to those of patients treated with
mastectomy over 15 years of follow-up.1–4
I have come to understand this surgery not only an
oncologic surgical procedure but also as a cosmetic opera-
tion. That is to say, it is generally good to preserve a
woman’s breast when treating a breast cancer. However,
this is only true if such treatment results in a breast that is
not deformed by such treatment and that a woman
believes is worth keeping or preserving (Figs. 9-1 to 9-3).
Obviously any operation that removes tissue from the
breast through a surgical incision with the subsequent
addition of radiation therapy virtually always alters the
breast. These changes involve every anatomic component
of the breast gland. There are changes in the skin pigmen-
tation, elasticity, and thickness. In addition, there are
often alterations of breast volume and contour and posi-
tion of the nipple areolar complex (NAC; Figs. 9-4 to 9-8).
As the prevalence of this technique has increased,
many experienced general and oncologic surgeons have
become increasingly aware of which breast cancer

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
421
FIGURE 9-2. A, Anteroposterior (AP) view of postlumpectomy defect following resection of 2-cm
tumor from upper outer aspect of left breast. B, Note scar is convex upward and located in upper outer
aspect of the breast. The excellent cosmesis is because size of resection is relatively small compared
with size of residual breast tissue.
FIGURE 9-1. Postlumpectomy defect with excellent cosmesis
following tumor resection from upper outer aspect of right
breast with subsequent radiation therapy.

422
Reoperative Plastic Surgery of the Breast
FIGURE 9-3. A, AP view of postlumpectomy defect in right breast with more significant asymmetry
after resection of larger tumor relative to the size of the breast. B, Lateral view with location of the scar.
This degree of asymmetry is still tolerated by most patients.
FIGURE 9-4. Subtle superior displacement of the NAC follow-
ing lumpectomy in upper aspect of the breast.
FIGURE 9-5. More significant deformity following resection of
lateral tumor in a relatively small breast.

patients are candidates for such procedures and which are
not, from the standpoint of the resulting breast cosmesis.
I believe that it is critical to select this option only in those
patients who are likely to achieve a satisfactory cosmetic
outcome.
Factors that are predictive of poor results are a large
tumor size relative to total breast size (large tumor in
small breast) (Fig. 9-9) and tumor location relative to NAC
(tumors immediately superior to or inferior to the NAC
cause more displacement of the nipple following treat-
ment; Fig. 9-10). Additionally, patients who require re-
excision after the first attempt at resection and those
developing wound problems, most notably infection, very
often show a poor cosmetic outcome. Patients such as
these are many times better off undergoing a mastectomy
and having an immediate breast reconstruction.
An early question was whether the surgical tumor exci-
sion or the adjuvant radiation therapy was more of a fac-
tor in the production a poor outcome. This question was
analyzed by Matory et al.,5 who verified that it was the vol-
ume of breast parenchymal resection relative to total
breast volume that was the most influential determining
factor in the genesis of the significant postlumpectomy
Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
423
FIGURE 9-6. Postlumpectomy deformity seen following resec-
tion of tumor in lower pole of left breast. This is bothersome to
the patient.
FIGURE 9-7. Significant volume asymmetry and displacement
of the NAC seen following lumpectomy to remove right breast
cancer that is bothersome to the patient.
FIGURE 9-8. Hyperpigmentation of the breast skin and
hypopigmentation of the NAC are seen in this African-American
patient following lumpectomy and radiation for bilateral breast
cancers.

424
Reoperative Plastic Surgery of the Breast
and radiation deformity. Radiation plays a role due to its
qualitative effect on the breast skin and remaining breast
parenchyma, but its effect is less significant than that of
surgical excision. In that same review, a comparison was
made of patients’, surgical oncologists’, radiation thera-
pists’, and plastic surgeons’ assessments of the overall
cosmesis using a scale of 1 to 10. The patients themselves
scored their own breast cosmesis most favorably. The cos-
metic outcome was scored with decreasing appeal by the
radiation therapists, surgical oncologists, and plastic sur-
geons, with the plastic surgeons issuing the lowest scores
for the quality of cosmetic outcome.
Several things are clear at the time of this writing. More
and more patients are being treated for breast cancer with
breast-conserving therapy (i.e., lumpectomy and radiation
therapy). As a consequence, more and more patients
are being seen by plastic surgeons for treatment of
postlumpectomy deformities that have resulted in objec-
tionable breast asymmetries. I personally continue to see
an ever increasing number of patients requesting correc-
tion of postlumpectomy deformities. Some of these
patients have presented after a second and sometimes even
a third excision that has been done to obtain a tumor-free
FIGURE 9-9. Significant deformity following lumpectomy
results from resection of a large tumor from a small breast.
There is marked contour abnormality, dislocation of the NAC,
and volume asymmetry.
FIGURE 9-10. A, Marked contour deformity has resulted from a large tissue resection from the lower
pole of the left breast in patient seen on AP view. It appears as if the lower hemisphere of the breast has
been removed. B, Note the marked dislocation of the NAC in an inferior direction and severe contour
deformity on lateral view.

margin. Some patients probably were not optimal
candidates for the procedure in the first place but were dis-
inclined to have a mastectomy. From my discussions with
these patients it appears that many of them had an unreal-
istic expectation regarding the outcome of such treatment.
I believe that general surgeons with whom I work
closely and who focus their practice on breast oncology do
a good job of selecting the patients who will not obtain a
good result from such treatment and steer such patients in
the appropriate direction of mastectomy. Nevertheless,
there are increasing numbers of patients who are present-
ing to plastic surgeons around the world with significant
deformities of their breasts following lumpectomy and
breast irradiation. Such problems vary both in their sever-
ity and in their contributing components. Because of this
it follows that successful treatment from the standpoint of
improving breast appearance requires a careful analysis
of each breast deformity with an individualized treatment
plan devised based on the patient’s chief complaint and
the surgeon’s physical examination of the breast(s).
This chapter overviews treatment options for the most
commonly presenting breast problems following lumpec-
tomy and radiation therapy for breast cancer. The treat-
ment options for postlumpectomy deformity are outlined
in Table 9-1.
PLASTIC SURGERY RECONSTRUCTION
OF THE LUMPECTOMY DEFECT
Patients seek reoperative breast surgery following a previ-
ous lumpectomy because of either breast asymmetry, with
an acceptable appearance of the breast that has under-
gone a breast-conserving procedure, or a deformity of the
ipsilateral breast that has undergone the tumor removal
and radiation therapy. Such deformities requiring surgical
reoperation for reconstruction are either moderate to sig-
nificant in their severity, and their correction may or may
not entail an adjustment of the opposite breast to opti-
mize symmetry. Moderate defects require reconstruction
methods that entail local tissue rearrangements, occasion-
ally the placement of an implant and often the provision
of a musculocutaneous flap or free tissue transfer.
Patients with an acceptable appearance of their ipsilateral
breast are often best treated with an adjustment of the
opposite breast in the form of a mammoplasty procedure.
RECONSTRUCTION OF ENTIRE BREAST
FOLLOWING COMPLETION
MASTECTOMY
Clough et al.6 have studied the outcome of such treatment
from the standpoint of patient satisfaction. Not surpris-
ingly, the patients with the greatest satisfaction following
reoperation are those who have opposite breast adjust-
ments. Interestingly, patients who underwent a comple-
tion mastectomy and reconstruction of their entire breast
were far more pleased than patients who had attempted
reconstruction of moderate defects of their ipsilateral
breast. To address the deformities in this group, many
authors have begun to enthusiastically support oncoplas-
tic surgery, or a tissue rearrangement of the breast under-
going lumpectomy at the time of that procedure and
before radiation.7–9 The initial analysis of such patients
appears to show a benefit in terms of the cosmetic
outcome. Throughout the remainder of this chapter I
overview reoperation after lumpectomy and do not com-
ment on oncoplastic surgery.
THE POSTLUMPECTOMY DEFECT
Postlumpectomy defects most often pose a significant
challenge for the plastic surgeon. What makes them diffi-
cult is that there is almost always a tissue deficit with
Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
425
TABLE 9-1
Postlumpectomy Deformities—a Treatment Approach
I.
Opposite breast adjustment surgery
a. Asymmetry—opposite (contralateral) breast modification
b. Shape—mastopexy
c. Volume—breast reduction
II. Reconstruction of the postlumpectomy defect (previously treated
or ipsilateral breast) with or without opposite breast adjustment
a. Scar—invagination
b. Redirect scars that are crossing contours
c. Contour asymmetry—treatment of ipsilateral breast
d. Contour deformity—local tissue shift, local flap
e. Peripheral fat injection
f. Volume augmentation—implant
g. Asymmetry of NACs—correction by relocation
III. Reconstruction of the postlumpectomy defect at the time of the
lumpectomy—oncoplastic surgery with or without opposite breast
adjustment
a. Mammoplasty—rearrangement of the ipsilateral breast at the
time of tumor resection
b. Possible flap reconstruction
IV. Completion mastectomy and ipsilateral breast reconstruction with
or without opposite breast adjustment
a. Recurrent tumor—completion mastectomy
b. Severe deformity not amenable to partial reconstruction
c. Reconstruction—vascularized tissue flap
d. Flap—latissimus dorsi—lateral defects, superior lateral
defects, some inferior defects
e. TRAM—central defects, inferior pole defects, medial defects
TRAM, Transverse rectus abdominis myocutaneous; NAC, nipple areolar
complex.

varying degrees of intraparenchymal fibrosis or cicatrix
and skin scarring, along with a global hypovascularity of
breast due to radiation. The degree of quantitative skin
deficiency varies, but there is always a qualitative skin
abnormality. Very often there is an element of nipple are-
ola displacement or dislocation in cases of larger skin
resection or significant parenchymal tissue resection,
with a corresponding contour abnormality of the breast.
Surgery on the postlumpectomy defect, by definition, is
always revisional or reoperative in nature.
The goals for treating postlumpectomy deformity are
similar to those espoused in the previous chapters of this
text. They are restoring symmetry by reconstructing con-
tour deficits and correcting tissue deficits in kind, with the
overall goal of restoring breast appearance as much as
possible to what the eye would see and the brain would
recognize as normal. There are additional constraints in
treating postlumpectomy deformity that are imposed by
the combination of radiation and scar effects from the
previous surgery(ies), and these must be outlined for each
patient by the surgeon preoperatively.
The important principles at play in reoperative surgery
in this group of patients are the same as those in the treat-
ment of every secondary defect. These include recreating
the deformity by releasing and resecting all scars, and
then reconstructing the defect. The defect resulting from
the intraparenchymal scar almost always requires some
sort of reconstruction procedure. This may entail reposi-
tioning of the residual breast pedicle and/or reshaping the
skin envelope of the ipsilateral breast, a partial recon-
struction of the breast with the addition of flap tissue,
completion of the mastectomy, and a reconstruction of an
entirely new breast.
It has been my experience that in most instances the
ideal reconstructive medium is vascularized tissue, which
brings in a new blood supply that can produce neovascu-
larization of the wound. Although the volume deficit is a
primary component in the genesis of the problem, an
implant alone is rarely the answer.5 Both modalities can
be used, as is illustrated later in this chapter, but my pref-
erence is for the addition of a well-vascularized tissue flap.
This has produced the best and most predictable outcome
over a wide range of patients and clinical situations.
Flap reconstruction of the postlumpectomy defor-
mity is complicated by the paucity of local flaps. Skin
rearrangements adjacent to the scar are suitable for only
the smallest and most superficial defects. There is a
paucity of local tissue. I have no experience with the lat-
eral thoracic skin flap because I believe that the donor
scar is prohibitive in most patients. This flap has been
described for postlumpectomy deficit reconstruction,
however.
The workhorses in my practice have been the trans-
verse rectus abdominis myocutaneous (TRAM) flap and
the latissimus dorsi flaps as illustrated later in this
chapter. These flaps can provide variable amounts of new
tissue, and their use in breast reconstruction is standard-
ized. The latissimus is excellent for defects situated later-
ally, superolaterally, and inferolaterally, while the TRAM is
better suited for the reconstruction of inferior, central,
and medial defects. To reconstruct defects in these loca-
tions with a latissimus flap, dissection through the breast
is required to position the flap. Therefore its use has been
limited in my hands to defects located in the outer half
and occasionally the inferior pole of the breast. The
TRAM flap (whether free or pedicled) is also the most use-
ful technique when there is a need for significant volume
restoration or skin replacement.
I believe that the volume of resected tissue relative to
the total volume of the breast is the most important deter-
minant in the genesis of the postlumpectomy deformity
(see Fig. 9-9). The next most critical factor is the location
of the resection. Tumor resections that are carried out
immediately above or immediately inferior to the NAC
are responsible for the large majority of postlumpectomy
deformities that require a major reconstruction, with the
resections in the inferior pole of the breast resulting in
the worst cosmetic outcomes (Fig. 9-11A,B). Other pre-
dictive factors for a poor outcome are reoperations for re-
establishment of a tumor-free margin and intervening
infection in the lumpectomy wound. Finally, better out-
comes at the site of the excision from the standpoint of
breast contour are seen in patients whose breast flaps are
kept thick as opposed to those patients whose skin flaps
are thin.
426
Reoperative Plastic Surgery of the Breast
FIGURE 9-11. A, Erythema and induration of the left breast
noted at the completion of radiation therapy after lumpectomy.
(continued)

The therapeutic radiation administered to the breast(s)
also plays a role in the etiology of the problems encoun-
tered by the reconstructive surgeon. It is has long been
accepted that radiation therapy produces effects on all tis-
sues subjected to it. These effects are indiscriminate (i.e.,
radiation therapy affects both the tumor cells and the sur-
rounding tissues), and they are permanent, continuous,
and progressive.
The injury produced by radiation therapy and the time
line of healing are generally understood as follows. The
acute phase of tissue repair following radiation therapy is
noted during and up to 6 weeks following such treatment.
It can be marked by redness, blisters, or frank ulceration
of the skin (Fig. 9-12A,B). After this time the skin exhibits
edema and definite induration. Clearly, advances in the
science of radiation therapy and refinements in the tech-
nology and instrumentation used for its administration
have dramatically decreased such acute radiation injury
to the skin and have almost completely eliminated persist-
ent skin ulceration. However, such presentations are occa-
sionally still seen (Fig. 9-13A–D).
The subacute phase of wound healing following such
treatment occurs over the ensuing 6 months and is
marked by hyperpigmentation and often a tactile quality
of woodiness in the breast tissues that is apparent to the
patient and the surgeon.
Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
427
FIGURE 9-12. A, Radiation therapy–induced ulceration in the inferior pole of the breast skin of this
60-year-old obese patient with insulin-dependent diabetes who was seen and treated by me 18 years
ago. The wound showed no sign of healing after 4 weeks of serial débridements and intensive wound
care. B, The wound was resected, including the NAC, in a fashion similar to an amputation breast
reduction.
FIGURE 9-11. (CONTINUED) B, Erythema, hyperpigmenta-
tion, and epidermolysis noted on right breast following mastec-
tomy with subsequent adjuvant radiation therapy.

428
Reoperative Plastic Surgery of the Breast
Understanding the time line of wound repair is impor-
tant from a surgeon’s prospective. I almost never consider
operating in the setting of previous radiation therapy until
at least 6 months has elapsed since the completion of the
therapy. This is important from both the standpoint of
wound healing following any additional surgery and from
the vantage point of tissue equilibrium and pliability,
which are necessary for the best cosmetic outcome follow-
ing additional surgical intervention.
Acute wound problems requiring surgical intervention
(i.e., radiation ulcers) are uncommon. When they occur
they are best treated initially with the application of baci-
tracin ointment, which promotes the maintenance of a
moist, bacteriostatic environment that optimizes wound
healing. In cases of a painful open wound I have found
that the application of topical lidocaine (Xylocaine) gel
(0.05%) may be helpful.
Persistent skin ulceration following radiation therapy
occurs rarely, but it may represent an indication for sur-
gery. The common denominator in the pathogenesis of
such a problem is local tissue ischemia, often with coexist-
ing subclinical wound infection and a medical comorbidity
FIGURE 9-13. A, Larger necrotic ulcer in the lower pole of the left breast of a 65-year-old obese
patient with insulin-dependent diabetes who has undergone a lumpectomy and radiation therapy for a
breast cancer. B, Appearance of the breast following resection of the entire lower pole in a fashion
resembling an amputation reduction mammoplasty. Patient’s wounds have healed and she is marked
for a contralateral breast reduction and a nipple reconstruction using a skate flap and full-thickness
skin graft on the left breast. The appearance of the breasts is noted 4 months after surgery (C) and 18
years after surgery (D).

such as diabetes mellitus or a vasculitis. To treat such a
problem typically two components are needed: an aggres-
sive surgical débridement of the skin and the deep tissue
injured by the radiation, most often with the simultaneous
provision of vascularized tissue to this ischemic wound
environment. This combination of surgical treatment of the
wound most often produces wound healing. Therapeutic
interventions consisting of vascularized tissue as therapy
are the most reliable methods for achieving wound healing.
When I have encountered problems with this schema they
have usually been the result of inadequate surgical débride-
ment that has left marginally perfused and/or contami-
nated tissue behind in the wound.
I treated a patient with radiation-induced tissue loss
approximately 18 years ago. The patient, very obese with
insulin-dependent diabetes, underwent a lumpectomy and
radiation therapy as treatment for a lower pole breast
tumor. She sustained a wound breakdown with ulceration
of the surrounding skin (Fig. 9-13A). This wound showed
no sign of healing despite serial débridements in the office,
along with an intense regimen daily dressing changes done
over a 4-week period. Multiple true cut needle biopsies of
the wound were negative for tumor and the wound cul-
tures did not grow any organisms. For this reason I excised
the wound, including the NAC, in a fashion similar to an
amputation breast reduction and it healed without inci-
dent (Fig. 9-13B). There was no residual tumor in the
resected left breast tissue specimen. After wound healing
was ensured we proceeded with a contralateral breast
reduction and left nipple reconstruction with a skate flap
and full-thickness skin graft from the groin (Fig. 9-13C).
The patient has been without breast problems for the ensu-
ing 18 years (Fig. 9-13D), showing only loss of nipple pro-
jection on the left breast and hypopigmentation of the skin
graft used to reconstruct the left areolar complex. Our data
indicate that patients with diabetes may be more predis-
posed to radiation-induced tissue injury in all areas of the
body than nondiabetic patients.10
SCARS FOLLOWING LUMPECTOMY
Scar tissue formation resulting from the deposition of col-
lagen is the way the body heals all wounds. In the case of
lumpectomy there is often one common scar between the
postresection wound cavity, which initially fills with
seroma fluid and then undergoes some degree of contrac-
tion, and the skin scar. Excessive contraction of this
underlying scar tissue/fluid space can be transmitted
throughout the depth of the wound, where contraction of
the scar mass may produce a depression of the contour
with invagination of the skin scar itself. If this occurs the
appearance is very often objectionable to the patient. The
extent of the resulting deformity may be increased by the
effects of the subsequent radiation therapy.
Such a patient presented with an invagination of a
lumpectomy scar in the upper aspect of her right breast
(Fig. 9-14A). This had been present since her lumpectomy
1 year earlier. In her case, and in many others like it, the
appearance can be improved by resecting the scar tissue
in the skin and tissues immediately beneath it and creat-
ing small flaps, or tongues, of adipose tissue on either side
of the wound that can be advanced toward the center of
the wound and interdigitated, or stacked, on one another.
This surgical approach is possible if the tissues adjacent to
the wound have regained sufficient suppleness and mobil-
ity to be advanced toward the center of the wound. In this
case the patient underwent a contralateral breast reduc-
tion (Fig. 9-14B) along with an excision of the scar and a
vertical stacking of the tissue in the wound. There was a
marked improvement in the symmetry between the
breasts but only a minimal improvement of the scar on
the right breast (Fig. 9-14C). She subsequently underwent
a reoperation on the scar. This consisted of a precisely
done lysis of the scar at the interface of the dermis with
the adipose layer (Fig. 9-14D) and the harvest of a der-
mis–fat graft from the skin excess along the lateral chest
wall from the previous breast reduction (Fig. 9-14E). This
was placed so that it precisely fit the wound (Fig. 9-14F).
At a 2-month follow-up the patient demonstrates a much
improved appearance of the scar (Fig. 9-14G).
BREAST ASYMMETRY FOLLOWING
LUMPECTOMY AND RADIATION
THERAPY
Breast asymmetry following lumpectomy and radiation
therapy is the most common reason that such patients seek
consultation with the plastic surgeon. Asymmetry can result
from contour deficits, breast volume discrepancies, differ-
ences in nipple areola position or appearance, and combi-
nations of these. Different degrees of such deformity require
different surgical approaches and treatment options for
their surgical correction. As with many areas of breast revi-
sion discussed in this book, correction of postlumpectomy
and radiation deficits is always discussed with the patient in
relative terms. That is to say, correction of these problems
must be thought of in terms of improvement, not perfection.
The concept of educating the patient as to what is possible
and what is not possible is very relevant when treating
patients with postlumpectomy deformity.
CORRECTION OF SMALL CONTOUR
DEFICITS—TISSUE SHIFTS
Small or subtle discrepancies in contour can be objection-
able to the patient. This is especially true if they involve
the NAC or the peripheral contours of the breast, either
Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
429

FIGURE 9-14. A, Postlumpectomy appearance in a patient who is seen approximately 1 year follow-
ing treatment for a right breast cancer and exhibits two problems: an invaginated scar of the right
breast producing a contour deformity and a breast asymmetry related to a significant volume discrep-
ancy. B, The first procedure was a combination of a left breast reduction along with an excision of the
scar on the right breast, lysis of deep adhesions, and a vertical Z-plasty with overlap of multiple tissue
flaps in the right breast beneath the scar. C, This only partially corrected the contour deformity of the
right breast. D, Patient underwent a dermis–fat graft of that area done with precise release of the cica-
trix beneath the scar. (continued)

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
431
FIGURE 9-14. (CONTINUED) E, Harvest of a dermis–fat graft
from the tissue excess along lateral chest wall on left breast.
F, Graft was harvested and placed dermis side up to precisely fill
the created wound. G, Patient is seen with an improved appear-
ance of the scar and improved contour of right breast at 6 months
following surgery.

medially, laterally, inferiorly, superiorly, or the central part
of the breast.
A small contour abnormality (most often an indenta-
tion) at the junction of the areola and breast skin follow-
ing lumpectomy can produce a depression of the NAC.
This can be treated with the advancement of a de-epithe-
lialized flap of skin adjacent to the areola if there is some
redundancy of skin and subcutaneous tissue in this loca-
tion. This de-epithelialized advancement flap can be used
as a foundation or a platform on top of which the NAC can
be reseated after it has been elevated after the scar tissue
has been lysed. This contour correction requires lysis of
the deep cicatrix in the breast beneath the scar in the skin.
Advancing small or medium flaps to de-epithelialized
skin to fill contour deformities is a common technique
that can be applied to correct contour deformities or step-
offs in contour in many settings. It is illustrated in
Chapter 2 (see Fig. 2-43). Often this can be done with only
a minimal increase in the total length of the skin scar,
especially in a location such as the periphery of the areola,
where the curved incision often allows it to be concealed.
AUTOLOGOUS FAT TRANSPLANTATION
FOR CONTOUR CORRECTION
Autologous fat transplantation is a modality that is gain-
ing popularity among plastic surgeons to treat a myriad of
clinical problems. This is certainly true for contour abnor-
malities in the breast.
The use of autologous fat transplantation to treat
postlumpectomy deformity is illustrated in Chapter 2 (see
Figs. 2-48 to 2-50) with regard to the treatment of a 55-
year-old patient with diabetes who underwent a lumpec-
tomy and radiation therapy to treat a left breast deformity
that resulted in a depression over her laterally positioned
scar at the site of her tumor resection. This was bother-
some to her. In addition she was bothered by a depression
in the superomedial aspect of the same breast that
resulted from the placement and subsequent removal of a
permanent intravenous (IV) access catheter or port used
for her chemotherapy.
The correction of these contour deformities was
achieved using autologous fat transplantation in two dif-
ferent forms. The area beneath her depressed scar was
corrected with the injection of autologous fat tissue that
was harvested from the lower abdomen in the infraumbil-
ical area. I prefer to harvest such fat by aspirating it with a
1.5-mm blunt-tipped cannula (see Fig. 2-44). Alternatively,
the lateral thigh or medial aspect of the knee often har-
bors excess fat that is a source for excellent quality adi-
pose tissue that can be transplanted. Regardless of the
donor area that is chosen, I believe it is important to inject
the adipose tissue with a local anesthetic agent that con-
tains epinephrine in a concentration of 1:400,000. After
injecting this into the region of the adipose tissue to be
harvested, I wait for at least 20 (and sometimes 30) min-
utes until there is a pronounced appearance of blanching
of the skin, which is indicative of vasoconstriction in the
adipose layer. This usually means that the harvested adi-
pose cells will be almost completely devoid of blood con-
tamination. The fat is harvested into 10-cc plastic syringes
that are then inserted into a sterile centrifuging at 3,000
rpm for 5 minutes, which makes it easy to separate the
cellular component from the infranatant fluid. This fluid,
which is composed of fatty oils, is then discarded and the
adipose tissue is loaded into 1-cc glass tuberculin
syringes, which are used to inject it into the recipient area
(see Fig. 2-45).
In the case of a deformity beneath a skin scar as small
as in this case, the skin scar must first be released. This is
done by injecting the scar with a local anesthetic contain-
ing epinephrine, which is again allowed to set up in the
tissue for 15 minutes. Next, a small sharp instrument is
passed immediately beneath the dermis along the scar to
release it from the deep tissues. This rarely results in any
bleeding. Then the adipose tissue is injected into the tis-
sue in strands, using the technique of lipostructuring as
described by Coleman.11 The small access incisions
needed to introduce the needles are created using a No. 11
blade scalpel to produce puncture wounds. It is important
to place the fat in multiple layers, including in the breast
tissue and subcutaneous space. It is very important to not
inject the fat in clumps. The fat is injected using the 1-cc
syringes through 14-gauge blunt-tipped needles. A slight
overcorrection of the deficit should be achieved. The inci-
sions used to inject adipose tissue are closed at the end of
the procedure using a 5-0 chromic suture. I then place a
piece of sterile nonstick topical foam over the area that
has been grafted. This is left in place for 5 days, during
which time the patient is maintained on oral antibiotics,
usually cephalexin [500 mg by mouth (PO) four times
daily (q.i.d.)]. If there is a history of penicillin allergy I will
use erythromycin [333 mg PO three times daily (t.i.d.)] as
an alternative medication. Correction of such deformities
has been possible in most cases. I inform the patient that
between 50% and 75% of the adipose tissue is likely to per-
sist at the site of injection, but that a definite possibility of
having to retreat the contour deformity following an
autologous fat cell injection certainly exists. Such retreat-
ments are usually spaced 6 months apart.
In this patient the depression at the site of the previous
port used for her chemotherapy was reconstructed with a
dermis–fat graft. I have found that such grafts provide
more structural stability and resistance to compression in
scarred areas as the healing of the fat graft proceeds.
The technique of dermis–fat graft harvest, removal of
the epidermis, and graft placement requires precision.
The area to be grafted is outlined and a template for the
graft is made with sterile glove wrapper paper (from the
432
Reoperative Plastic Surgery of the Breast

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
433
surgical gloves). The intended graft is outlined on the skin
and de-epithelialized. The graft is harvested and only the
superficial layer of adipose tissue (the layer of fat above
the superficial fascia) is used. I will occasionally harvest
additional segments of the superficial fascia to use as sep-
arate fingers of the graft in defects that are irregular and
where these additional strands of tissue can be used
to treat multiple recesses in a particular defect. The
dermis–fat graft is placed with the dermal surface posi-
tioned superficially against the overlying dermis.
When the recipient bed is prepared for such a graft the
surgical dissection must be precise from the standpoint of
hemostasis and dimension. Once again I prefer to use a
local anesthetic containing epinephrine, and I will per-
form the dissection through one or two small incisions
using a scalpel. I will use a headlight with an appropriate
retractor (Senn, or cat’s paw) to achieve exacting hemosta-
sis in the wound. I will then insert the dermis–fat graft,
often using an attached pull-out suture at its lead edge to
precisely position it. At times I will secure the graft using
three or four sutures brought through the skin, which are
tied over bolsters. When such fixation sutures are used
they are removed by the fifth postoperative day. In gen-
eral, the thickness of such grafts should not exceed 1 cm.
There is normally a period of induration of these grafts
that lasts approximately 3 months, after which a tactile
sensation of softness returns to them.
I have been impressed by the utility of both of these
techniques for correcting small contour deficits. They
both achieved a very satisfactory correction of the deficits,
which is seen in this patient at 1 year following surgery
(see Figs. 2-58 to 2-60).
USE OF COMBINED DERMIS–FAT
GRAFTS AND AUTOLOGOUS FAT
INJECTION FOR LARGER DEFICITS IN
THE NONRADIATED PATIENT
Postlumpectomy defects can present themselves in various
sizes or in various shapes and dimensions. Larger defects
can sometimes require a combination of dermis–fat graft-
ing to the central portion of such a defect with autologous
fat injection at the periphery.
Such a case is illustrated by this 72-year-old patient
(Fig. 9-15), who underwent a lumpectomy for what turned
out to be a benign disease. She had tissue excised from the
inferolateral quadrant of her breast that resulted in a very
noticeable and bothersome contour deformity for which
she sought correction (Fig. 9-15A,B). She had not received
radiation therapy to the breast.
We considered many options for correction but I felt
that the combination of a dermis–fat–fascia graft used in
conjunction with autologous fat transplantation was the
FIGURE 9-15. Breast deformity in lower outer aspect of right breast following a resection of a benign
lesion on AP view (A) and lateral view (B). (continued)

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Reoperative Plastic Surgery of the Breast
FIGURE 9-15. (CONTINUED) C, The plan is for reconstruction with a combination of
a dermis–fat–fascia graft and autologous fat injection. Patient is marked for the insertion of the der-
mis–fat–fascia graft. D, Additional marks are made for placement of the fat injections. E,
Dermis–fat–fascia graft is a composite harvested from the right lower abdomen through a previous scar
and includes a segment of the superficial fascia. F, Fat has been aspirated and centrifuged. (continued)
best option. The area to undergo the placement of the der-
mis–fat graft was outlined first (Fig. 9-15C), and subse-
quently the sites of autologous fat injection and the sites
of donor fat harvest were marked (Fig. 9-15D). In this case
the suprapubic region was the site of the dermis–fat graft
harvest, and the autologous fat graft was obtained from
the infraumbilical adipose tissue depot. We harvested the
dermis with the superficial fat and segments of the super-

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
435
ficial fascial system. The fascial extensions (raised as a
composite with the dermis–fat graft) were useful to fill
and reconstruct multiple recesses of her defect (Fig. 9-
15E,F). In addition, 30 cc of autologous fat was processed
(Fig. 9-15G) and injected peripheral to the major portion
of the defect (Fig. 9-15H). She exhibited a very satisfactory
correction during a 3-month postoperative follow-up visit,
which was maintained (Fig. 9-15I).
THE POSTLUMPECTOMY PLUS
RADIATION DEFORMITY
At the time of this writing I am acquiring experience using
autologous fat injections in patients who have been
treated with surgery and radiation. The best candidates
are those patients with peripheral defects. The take of the
transplanted fat appears to be less reliable than the take in
FIGURE 9-15. (CONTINUED) The fat is injected with 1-cc
syringes through a 14-gauge needle (G). The appearance at 2
months following surgery on AP view (H) and oblique view (I).

nonradiated patients. This is because of the decreased
vascularity in the area of the lumpectomy, but also
because of the dense cicatrix. An unsuccessful take may
result in calcifications within the fat graft. When such
calcifications in the area of fat transplantation occur,
they are usually easily distinguished by an experienced
radiologist or surgeon from the calcifications that are
worrisome for the suggestion or malignant disease.
Although the technique of fat injection shows promise
for use in postlumpectomy defects, such patients must be
advised of the increased possibilities of suboptimal sur-
vival and the fact that they will require special mammo-
graphic surveillance to closely follow the treated area for
the occurrence of calcifications. If at any time there is a
question about the nature of such calcifications, addi-
tional biopsies of these areas may be needed.
CONTOUR ABNORMALITIES TREATED
WITH IMPLANTS
More significant contour deficits in the breast require
more aggressive methods of correction. For medium-sized
defects this most often means consideration of using an
implant. The major drawback of placing an implant to
augment or reconstruct any breast is the predictable scar
tissue capsule that forms around every implant and the
unpredictable tendency of such a capsule to contract. In
most situations advanced forms of this capsular contrac-
ture are uncommon. However, my experience has taught
me that following previous radiation to the breast there is
a definite increase in the tendency for advanced forms
(Baker III and IV) to occur. The resulting breast firmness
may be very bothersome to the patient.
Nevertheless, in many cases of moderate to significant
contour (and volume) discrepancies following previous
lumpectomy and radiation therapy to the breast, treat-
ment of these problems with an implant has appeal for
both patients and surgeons. This is because the procedure
requires only a small incision on the breast, and there is
no donor flap morbidity that would accompany a flap
procedure.
When implants are used for postlumpectomy recon-
struction, the best results are obtained in patients who have
significant residual breast tissue and relatively thick breast
flaps raised during the lumpectomy. Such implants should
almost always be placed in the submuscular position.
Generally, the smaller the defect, the better the result. When
dissecting the recipient submuscular pocket the surgeon
should outline the specific contour deficit to be corrected
and precisely dissect the pocket in which the previously
selected implant is to be placed. I use dimensional concepts
for selecting such an implant, and in general I prefer saline
implants because I believe they confer an advantage in
terms of having a lesser tendency to develop advanced cap-
sular contractures. Maintaining meticulous hemostasis and
using suction drains are routine.
An example of a favorable outcome following such
treatment is illustrated by this patient (Fig. 9-16A,B), who
underwent lumpectomy and radiation to treat a breast
cancer superior to the NAC. Note that this patient had full
B cup–sized breast tissue even after the treatment with
surgical resection and radiation. She was bothered by
both the volume difference in terms of breast size and the
deficit in contour of the superior and lateral aspect of her
right breast adjacent to the NAC. She underwent recon-
struction of this deformity with the submuscular place-
ment of a smooth-walled round saline implant (9.6 cm,
125 cc). The outline for precise pocket dissection is
depicted (Fig. 9-16C). Postoperatively she demonstrates
improved symmetry between the breasts with relatively
good softness of the breast implant (Fig. 9-16D,E). She
was noted to have Baker II capsular contracture, but the
opposite breast exhibited a significant amount of firm
stromal tissue.
This result persisted for 2 years until she developed
recurrent disease that required an additional lumpectomy
and additional local radiation to the breast. She subse-
quently developed a deflation of her implant and required
an implant exchange to a higher-profile implant with a
larger saline volume (9.6 cm, 230 cc; Fig. 9-16F). A resec-
tion of the previous anterior periprosthetic capsular tissue
was performed in an attempt to maximize implant projec-
tion directly beneath the upper aspect of the NAC but with
limited success. She remains pleased at a 14-month fol-
low-up, although the contour deficit with slight flattening
of the NAC persists (Fig. 9-16F,G). This is most apparent
in certain postures and is very visible when the patient
bends forward (Fig. 9-16H).
In this case the use of a saline implant was successful
in improving volume asymmetry and correcting the con-
tour deficit without significant capsular contracture. This
is one of the better results that I have obtained from the
use of an implant in this setting. A major decrease in the
quality of the breast appearance was produced by the sec-
ond lumpectomy and additional radiation therapy.
Unfortunately capsular contracture of advanced degree
(Baker III, IV) is also quite common when using implants
in this setting. Such an example is illustrated by this
case wherein this 44-year-old patient underwent staged
reconstruction of the left breast to correct both a volume
deficit and contour asymmetry following breast cancer
treatment with lumpectomy and radiation therapy (Fig. 9-
17A). On the oblique view the extreme lateral dislocation of
the NAC is noted (Fig. 9-17B). We used a tissue expander
placed in the submuscular position that was overfilled (12
cm, 525 cc) and maintained as such for 6 months. This was
carried out in conjunction with a right transaxillary breast
augmentation using a smooth-walled saline implant (11.9
cm, 330 cc) (Fig. 9-17C,D). This was exchanged for a
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Reoperative Plastic Surgery of the Breast
(text continues on page 440)

FIGURE 9-16. A, Postlumpectomy deformity in right breast of a young patient following resection
of a small tumor immediately above the NAC with subsequent radiation therapy. B, Oblique view.
C, Patient is marked for placement of a small subpectoral implant positioned to maximally correct vol-
ume and contour deficits. This option was chosen because patient has a significant amount of her own
breast tissue. D–E, Improved symmetry and a better breast appearance are noted postoperatively at 8
months. (continued)

FIGURE 9-16. (CONTINUED) F, G, Patient underwent a second lumpectomy for recurrent disease
and has a nipple dislocation and flattening of the contour in the area of reresection and desires addi-
tional corrective surgery. High-profile implant with greater volume was placed, which improved her
appearance somewhat, but she has a contour defect that has not been completely corrected (H) and is
more visible in certain postures, especially when bending forward.

Chapter 9
Reoperative Surgery Following Lumpectomy and Radiation Therapy
439
FIGURE 9-17. Another postlumpectomy deformity following treatment of a small, laterally located
left breast cancer. A, Note nipple displacement and asymmetry of lateral breast contour on AP view. B,
Oblique view shows nipple displacement. C–D, First stage of reconstruction involved the placement of a
tissue expander (12 cm, 525 cc) to reconstruct the lateral breast contour. Radiated tissue was difficult to
expand. (continued)

440
Reoperative Plastic Surgery of the Breast
shaped textured saline implant (base width 13 cm, height
14 cm, volume 490 cc) at a second stage. The wider base
width implant gives slightly more of an illusion that the lat-
eral nipple dislocation is better corrected (Fig. 9-17E). After
an initial satisfactory result the patient developed a Baker
IV capsular contracture that was unresponsive to high dose
of vitamin E (Fig. 9-17E,F). As of this writing she is consid-
ering autogenous conversion using a TRAM flap.
SURGICAL MODIFICATION OF THE
OPPOSITE BREAST FOLLOWING
LUMPECTOMY AND RADIATION
THERAPY
The treatment strategy that has the highest degree of
patient satisfaction is where only the opposite breast is
altered. This implies that the patient is satisfied or reason-
ably satisfied with the appearance of the ipsilateral breast
treated by the lumpectomy. The options for the contralat-
eral breast are a mastopexy or a breast reduction.
The vertical mastopexy procedure has been well suited
to this population of patients because breasts treated by
lumpectomy and radiation therapy often appear rounder
and almost uplifted when compared with the opposite
breast. Examples of this situation are illustrated by the
following two cases. The first is a 55-year-old patient who
underwent a left lumpectomy and radiation therapy for
breast cancer. She presented for correction of the result-
ing breast asymmetry marked by a difference in volume,
nipple position, nipple areolar inclination, and degree of
ptosis (Fig. 9-18A). The asymmetry was addressed by per-
forming a vertical mastopexy (Fig. 9-18B) on the opposite
right breast. At a 1-year follow-up examination after surgery
the patient demonstrates markedly improved breast aes-
thetics in terms of symmetry despite the persistent nipple
areolar asymmetry due to the laterally displaced nipple on
the left breast.
FIGURE 9-17. (CONTINUED) E–F, Subsequent implant placement (shaped textured saline, 13 cm, 490
cc) provides a suboptimal-appearing reconstruction and resulted in a Baker III capsular contracture.