Atlas Các Kỹ Thuật Phẫu Thuật Tuyến Vú (Atlas of Breast Surgical Techniques)

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 257
A
B
C
Figure 18-6
Anterior
axillary line
Normal fold
height
Midline
Figure 18-7
Figure 18-8

258 Section IV • Mastectomy
◆ Botox (botulinum toxin type A; Allergan, Irvine, CA) 100 IU diluted in 60 mL of injectable
normal saline is injected in the PM using a 21-gauge spinal needle in a fan shape (Fig. 18-9).
The objective is to diminish muscle spasm, and thus pain, immediately after surgery and during
expansion over the next several months.
◆ Bupivacaine HCl (0.25%) without epinephrine (Hospira Inc., Lake Forest, IL) is injected in the
chest wall muscles to diminish immediate postoperative pain. A 21-gauge spinal needle is used
and the injection proceeds in a fan shape, as in Figure 18-9, B. The serratus, teres, and latissi-
mus dorsi are also injected.
◆ To dissect the expander pocket, the PM is dissected from the chest wall, starting from its lateral
edge using the electrocautery (Figs. 18-10, A and B); then, by digital dissection, the muscle is
easily detached from the chest wall in its upper two thirds (Fig. 18-10, C and D). In the inferior
aspect the muscle is fi rmly attached to the chest wall and the dissection requires electrocautery
(Fig. 18-10, E). Dissection of the PM from the pectoralis minor (PMi) proceeds in the upper
lateral aspect of the pocket.

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 259
A
B
Figure 18-9
Skin opening
after mastectomy
Proposed incision
in serratus anterior
Proposed incision along
lateral border of pectoralis
major muscle
A
C
D
E
PMi
Figure 18-10
B

260 Section IV • Mastectomy
◆ The tissue expander is carefully inspected for leaks or nicks before use. A 21-gauge butterfl y
needle is inserted in the magnetic port, air is removed from the tissue expander (Fig. 18-11, A),
and 5 mL of methylene blue is injected (Fig. 18-11, B) to serve as a monitor for leaks during the
case. The expander is immersed in saline to check for leaks before implantation (Fig. 18-11, C).
A new pair of gloves is worn before touching and handling the tissue expander.
◆ The tissue expander is positioned in the submuscular pocket (Fig. 18-12). Any muscular bands
that may distort the expander must be transected with electrocautery. If the pocket is too small,
the expander may not have adequate room to unfold, increasing the risk of tissue erosion. If
the pocket is too large, the expander may not remain in proper position for fi lling and expan-
sion. Extreme care should be taken to avoid damage to the expander during surgery.

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 261
A
B
C
Pectoralis major
Figure 18-11
Figure 18-12

262 Section IV • Mastectomy
◆ Alloderm (Lifecell, Brauchberg, NJ), a regenerative tissue matrix allograft, is used to close the
lateral aspect of the muscular pocket. A 12 × 4-cm, medium-thickness, previously hydrated
Alloderm (Fig. 18-13, A) is applied to the lateral edge of the PM and sutured with a continuous
running 3-0 polyglactin 910 (Vicryl; Ethicon, Somerville, NJ; Fig. 18-13, B). The lateral edge
of the Alloderm is cut to fi t the defect and sutured in the same fashion to the serratus anterior
muscle (Fig. 18-13, C). Separate, simple interrupted sutures of 3-0 Vicryl are applied every
2 cm for reinforcement of the suture line.
◆ Muscle defects can also be reconstructed with Alloderm.
◆ When the PM origin is too high in relation to the inframammary sulcus (Fig. 18-14), the inferior
muscle edge is detached from the chest wall and an inferolateral sling of Alloderm is constructed
and sewn in similarly to accommodate the expander (Fig. 18-15). Two pieces of 12 × 4-cm of
Alloderm may be required.
◆ If the incision is remote from the site of expansion, the expander may be fi lled to tissue
tolerance at the time of surgery. If wound stability or skin viability is a concern, infl ate only
slightly to fi ll the pocket space without applying undue tension to the overlying tissues
(see Fig. 18-15).
◆ A closed drain system is applied, using a 15-Fr Blake drain (Bard, Covington, GA), brought out
through a separated stab wound in the medial axillary line at the level of the inferior mammary
sulcus. It is secured with a 2-0 nylon suture. The drain is connected to a closed wound suction
evacuation bulb reservoir (ReliaVac; Bard).
◆ The wound is closed with simple interrupted 3-0 Vicryl at the subcutaneous level, a continuous
running 5-0 poliglecaprone 25 (Monocryl; Ethicon) suture at the skin level, and two layers of
Dermabond (Ethicon).

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 263
A
B
C
Pectoralis
major muscle
Proposed
inframammary fold
Proposed partial
division of pectoralis
major muscle
Figure 18-13
Figure 18-14
Figure 18-15

264 Section IV • Mastectomy
Step 4. Postoperative Care
◆ A liquid skin adhesive (Dermabond; Ethicon) is applied to the incisions.
◆ No dressing is applied over the reconstructed breast to avoid undue pressure over the skin
fl aps.
◆ Dressings are applied only to the drain.
◆ Antibiotics and analgesics are administered.
◆ Exercises using the upper extremities are avoided in the fi rst 2 weeks, including driving.
◆ A petroleum-based ointment is applied after the ninth postoperative day. The dry Dermabond
will peel with ease, and the sutures can then be removed.
1. Tissue Expander Filling
◆ The wound should be stable before tissue expansion begins.
◆ Although the injection port usually can be identifi ed by palpation, a port locator should always
be used to verify its location and orientation. There are a variety of port locators, instruments
that correspond to the different brands of tissue expanders.
◆ The PMT Integra tissue expander (PMT, Chanhassen, MN) has a locator that produces light
when in contact with the metal port. Its circular periphery is determined, and the center is
localized (Fig. 18-16, A). The PSS H Umbrella tissue expander (SSP, Victor, MO) magnetic
injection port locator determines the center of the port in an absolutely perpendicular manner
(Fig. 18-16, B). The Mentor tissue expander (Mentor, Irving, TX) port locator has a small
magnetic pendulum that straightens over the center of the port (Fig. 18-16, C).
◆ Infl ation is typically performed in sessions spaced at weekly intervals. Unnecessary delays may
produce a resistant capsule.
◆ To avoid contamination, each infl ation session is performed using sterile draping and a closed
fi lling system.
◆ Fill volumes during each session depend on the patient and tissue tolerance. The initial volume
is usually between 100 and 150 mL of sterile injectable saline and is delivered using a 21-gauge
needle. The needle should enter perpendicular to the top of the injection port. Expansion should
proceed in moderate increments of approximately 50 mL per session. A patient fi ll volume
record is maintained.
◆ A certain amount of clear drainage normally accumulates around the expander and will appear
at the site of the injection.
◆ The expansion ideally continues until the desired volume chosen by the patient is exceeded by
10% to 20%. This will help overcome the normal retraction of the skin.

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 265
A
B
C
Figure 18-16

266 Section IV • Mastectomy
2. Exchange of Tissue Expander for Saline Implant
◆ A second-stage surgery to exchange the tissue expander for permanent saline implants is sched-
uled when the expansion is completed.
◆ Skin is marked to determine the areas that will require capsulotomies (C), capsuloplasties (CA),
liposuction (L), or lipectomies (LI). Capsular contractures, displacements of the expander,
and irregularities of the subcutaneous tissue or axillary skinfold are the indications for these
procedures (Fig. 18-17).
◆ A 5-cm incision is made in the lateral aspect of the original mastectomy scar (Fig. 18-18, A).
The capsule is incised with the electrocautery.
◆ The expander is defl ated using an 18-gauge needle attached to a tuberculin syringe modifi ed
to serve as an adaptor to the suction tubing.
◆ The expander is removed with a Kelly clamp, avoiding damage to the capsule (Fig. 18-18, B).
◆ The capsular pocket is examined for possible band formations, deformities, contractures, or
tumor.
◆ Capsulotomies under direct visualization (see Fig. 18-17) are performed usually in the medial
and inferior sites of the capsule, if indicated.

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 267
A
Incision in prior mastectomy scar
Incision in prior mastectomy scar
B
Figure 18-18
L = Liposuction
LI = Lipectomy
C = Capsulotomy
CA = Capsuloplasty
L
C
CA
LI
Figure 18-17

268 Section IV • Mastectomy
◆ Capsulorrhaphies using 3-0 Vicryl sutures are performed in the lateral or inferior sites of the
capsule under direct visualization, in cases of lateral or inferior displacement of the expander
(Fig. 18-19).
◆ Axillary lipectomies are performed when excess subcutaneous tissue and skin form extra folds
of skin in the axilla, causing discomfort (see Fig. 18-17).
◆ Liposuction of localized areas of excess subcutaneous tissue (see Fig. 18-17) can be performed
to optimize cosmesis. The demarcated areas are infi ltrated with epinephrine 1:200,000 to
diminish bleeding. Then excess fat is removed through a 2-mm incision using a 2-mm
cannula.
◆ A saline implant, smooth round high or medium profi le, of the chosen volume, is connected
to special tubing (Fig. 18-20, A).
◆ Simple interrupted 3-0 Vicryl sutures are applied to the capsular opening and left untied, tagged
with hemostats.
◆ The implant is defl ated and introduced into the submuscular capsular pocket (Fig. 18-20, B).

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 269
Anterior
capsule wall
Posterior
capsule wall
Proposed new
fold marked
on posterior capsule
B
A
B
Figure 18-20
Higher new
fold height
Selected implant
in pocket
Preexisting
fold height
A
Figure 18-19

270 Section IV • Mastectomy
◆ The saline implant is infl ated with sterile injectable saline to the desired volume using a closed
fi lling system (Fig. 18-21). When the desired result is achieved, the tubing is removed and the
valve is closed. The sutures are then tied. Closure is completed with Vicryl 3-0 simple inter-
rupted subcutaneous sutures and, in the skin, a 5-0 Monocryl continuous running suture.
Dermabond is applied in two layers.
◆ A sports bra may be applied loosely.
◆ The patient is given analgesics and kept on a postoperative course of oral antibiotics until the
drains are removed.
3. Nipple–Areolar Complex Reconstruction
◆ Patients who have had a modifi ed radical mastectomy (see Fig. 18-4, A) or skin-sparing mastec-
tomy (see Fig. 18-4, B) may desire reconstruction of the nipple-areolar complex (NAC).
◆ Mark the NAC site with the patient in a sitting position. The NAC is located approximately at
18 to 19 cm from the suprasternal notch (Fig. 18-22).

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 271
A
18-19 cm
B
Figure 18-22
Dual
check
valve
Saline I.V.
Implant
Fill tube
Luer connector
60-mL
syringe
A
Figure 18-21
B

272 Section IV • Mastectomy
◆ The site of the new areola disk is de-epithelialized using a no. 15 blade, taking care to remove
only the epidermis and leaving the dermis viable to accept the skin graft (Fig. 18-23).
◆ Hemostasis is achieved with electrocautery.
◆ A 1-mm circular skin frame is left intact surrounding the de-epithelialized new nipple site.
◆ A small pocket is dissected under the nipple site. A 3-mm incision is done in the lower aspect
of the skin frame and a tenotomy scissors is used to undermine the pocket. Three layers of
thick Alloderm, previously hydrated, are placed in the pocket for greater nipple projection. The
pocket is closed with Monocryl 5-0 simple interrupted sutures.
◆ A circular, full-thickness skin graft is harvested from the elbow skin and is sutured to the skin
frame using 6-0 Monocryl. The donor site at the elbow is closed with Vicryl 3-0, Monocryl 5-0,
and Dermabond.
◆ When possible, nipple sharing from the opposite breast is used instead of the elbow graft.

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 273
A
B
C
D
Figure 18-23

274 Section IV • Mastectomy
◆ To reconstruct the areola, a full-thickness skin graft is harvested from the medial aspect of the
upper thigh and defatted. The graft is sutured to the reconstructed breast using nylon 5-0 bolster
sutures. In the center of the areola graft, a 7-mm diameter disk of the skin graft is excised to
expose the new nipple. A Monocryl 6-0 continuous running suture complements the closure
in the periphery of the areola graft. The bolster dressing (petrolatum gauze and cotton balls) is
tied over the skin grafts (Fig. 18-24). Figure 18-25 shows the fi nal result.
Step 5. Pearls and Pitfalls
1. Pearls
◆ Use capsulotomies and capsuloplasties to correct irregularities not corrected by the tissue
expander.
◆ Avoid overdissection of the lower breast capsule to prevent migration of the expander to the
abdomen. This problem is quite diffi cult to correct.
2. Pitfalls
◆ Malpositioning and curling of the tissue expander may lead to inadvertent puncture of the
expander and defl ation, requiring replacement.
◆ Extrusion is more common when the expansion is performed in previously irradiated tissues.
Therefore, expansion in this situation should be performed slowly.
◆ Tight-fi tting bras worn postoperatively may cause skin ischemia.
◆ Necrosis of the native skin fl aps of the mastectomy and infection are the most serious complica-
tions that may lead to the abortion of the reconstruction. Necrosis must be dealt with aggres-
sively and urgently to avoid the possibility of infection.
Bibliography
Hochberg J, Beck BS, Yuen CJ, et al: Reconstruction of the nipple-sparing total mastectomy. Plast Reconstr Surg 2006;118:147-148.
Hochberg J, Layeeque R, Klimberg S, et al: Botulinum toxin (BT) infi ltration for pain control after mastectomy and subpectoral tissue
expansion. Plast Surg Forum 2004;27:190.
Hochberg J, Margulies A, Yuen CJ, et al: Alloderm (acellular human dermis) in breast reconstruction with tissue expander. Plast Reconstr
Surg 2005;116:126-127.
Layeeque R, Hochberg J, Klimberg S, et al: Botulinum toxin infi ltration for pain control after mastectomy and expander reconstruction.
Ann Surg 2004;240:608-613.
Margulies AG, Hochberg J, Klimberg S, et al: Total skin sparing mastectomy without the preservation of the nipple/areola complex. Am J
Surg 2005;190:907-912.
Povoski SP, Hochberg J, Ardenghy M, et al: Aggressive surgical resection and reconstruction for locally recurrent and focally advanced
breast cancer. Plast Surg Forum 2002;269-271.

Chapter 18 • Breast Reconstruction Postmastectomy with Tissue Expanders 275
Figure 18-24
Figure 18-25

Common Goals of Breast Reconstruction
◆ Create breasts of equal volume and similar contour.
◆ Balance the inframammary folds.
◆ Conceal and maintain symmetry between scars on each breast.
◆ Provide medial fullness to the reconstructed breast to create cleavage.
◆ Design the autologous tissue fl ap to position the most vascularized region in the most critical
aspect of the reconstructed breast (inferomedial aspect) and the least vascularized region later-
ally, adjacent to the axilla.
◆ Secure the reconstructed breast on the chest wall to avoid shifting into the axilla.
◆ Create a reconstructed breast with a soft, natural texture by optimizing the blood supply to the
fl ap that will decrease the occurrence of fat necrosis and atrophy.
◆ Minimize donor site morbidity by limiting the harvest of muscle and fascia.
A. Latissimus Dorsi Myocutaneous Flap for Repair
of a Partial Mastectomy Defect
Step 1. Surgical Anatomy
◆ The thoracodorsal vessels provide the main blood supply to the latissimus dorsi (LD) fl ap
(Fig. 19-1).
Tissue Breast
Reconstruction
Donald P. Baumann and Steven J. Kronowitz
CHAPTER 19
276

Chapter 19 • Tissue Breast Reconstruction 277
Circumflex
scapular artery
Thoracodorsal
artery
Latissimus dorsi
muscle
Crossing branch to
serratus anterior
muscle
Subscapular
artery
Lateral thoracic
artery
Axillary
artery
Figure 19-1

278 Section IV • Mastectomy
Step 2. Preoperative Considerations
◆ Depending on the location of the tumor, the relative defect size (defect volume/breast volume),
and the need to resect breast skin, a breast deformity that results from segmental mastectomy
can be repaired with either an LD myocutaneous fl ap or with oncoplastic techniques with
rearrangement of the remaining breast tissue.
◆ LD fl aps are well suited to reconstruct large lateral defects, especially in small-breasted patients
(C-cup breast or smaller) because these patients often have insuffi cient remaining breast tissue
to rearrange after the segmental mastectomy.
◆ An LD fl ap can also be used to reconstruct a postradiation deformity after breast-conserving
therapy when autologous tissue is preferred. The use of a transverse rectus abdominis myocu-
taneous (TRAM) fl ap is not recommended so it can be preserved for future reconstruction needs
in the event a total mastectomy should become necessary.
◆ An estimated 20% defect in the upper outer quadrant of the breast is shown in Figure 19-2.
◆ Given the small size of the breast, large defect size, and favorable location of the defect (adjacent
to axilla and TD vessels), an immediate repair can be performed with a pedicled LD fl ap.
Step 3. Operative Steps
1. Preoperative Markings
◆ The patient is marked before surgery in the standing position. Breast markings include the
sternal notch, midline, inframammary fold, and superior border of the breast. The anterolateral
border of the LD is marked while the patient adducts her upper extremity (Fig. 19-3). The
scapular tip, iliac crest, and posterior midline are then marked. The skin defect is estimated
and transposed to the skin island of the fl ap. The location of the skin island of the fl ap is posi-
tioned overlying the LD to allow for an adequate arc of rotation into the breast defect. The skin
paddle (outlined in red) is oriented within the patient’s bra strap line so that the donor site can
be concealed.
2. Intraoperative Patient Positioning
◆ The patient is positioned in the lateral decubitus position for fl ap harvest and donor site closure.
Flap insetting is performed with the patient supine and then upright, with the upper extremities
abducted 90 degrees and padded to avoid injury to the shoulder and brachial plexus.

Chapter 19 • Tissue Breast Reconstruction 279
A
B
Figure 19-2
Figure 19-3

280 Section IV • Mastectomy
3. Flap Dissection
◆ The skin island is incised to the level of the LD fascia (Fig. 19-4, A).
◆ The anterior border of the LD muscle adjacent to the serratus anterior (SA) muscle, the posterior
border adjacent to the trapezius muscle, along with the superior border adjacent to the teres
muscles are identifi ed to clarify the extent of the fl ap harvest.
◆ Dissection of the posterior surface of the LD is carried out by separating the muscle from the
underlying SA (Fig. 19-4, B).
◆ Care must be taken to ligate the thoracolumbar perforators. Attention must be given to the
location and course of the TD vascular pedicle, located on the undersurface of the muscle
(superior anterior border), to avoid vascular compromise to the fl ap. When dissecting the fl ap
toward the scapular tip, the plane of dissection must be just deep to the LD to avoid elevating
the subscapular fat pad or serratus posterior muscle.
◆ Next, the LD is transected inferiorly, allowing the muscle to be elevated off the posterior chest
wall and the dissection continued superiorly toward the TD pedicle.
◆ The other branches of the subscapular vessels to the SA, the circumfl ex scapular vessels, can
be ligated to gain added vascular pedicle length for the fl ap’s arc of rotation (Fig. 19-4, C).
◆ The TD nerve, situated medial to TD artery and vein, is transected to prevent postoperative
muscle contraction that can detract from the aesthetic outcome of the repair.
◆ Similarly, the humeral origin of the LD can be divided to improve the arc of rotation and mini-
mize muscle contracture. This region should be sutured to the lateral edge of the pectoralis
major muscle to prevent undue tension or torsion on the TD vascular pedicle and recreate the
anterior axillary fold, which leads to a more aesthetically pleasing result.
◆ A tunnel is created to transpose the fl ap into the segmental mastectomy defect (Fig. 19-5, A).
4. Donor Site Closure
◆ The donor site closure is performed after placement of closed-suction drains.
◆ The Scarpa fascial layer is closed with 2-0 absorbable sutures to decrease tension on skin
closure.
◆ The subcutaneous layer is closed with 3-0 absorbable sutures and the dermal closure is per-
formed with a running subcuticular 4-0 absorbable suture.
◆ The patient is then repositioned supine on the operating table for fl ap insetting.

Chapter 19 • Tissue Breast Reconstruction 281
A. Dissection of latissimus muscle from underlying
serratus anterior muscle and chest wall
B. Exposure of thoracodorsal vessels and crossing
branch to serratus anterior muscle
C. Ligation of crossing branch to serratus anterior
muscle
Figure 19-4
A. Flap transposition into partial
mastectomy defect
B. Diagrammatic view of musculocutaneous
blood supply
Figure 19-5

282 Section IV • Mastectomy
5. Flap Insetting
◆ The fl ap is delivered to the segmental mastectomy defect and its perfusion inspected. The patient
is placed in the sitting position and the fl ap contoured to fi ll the volume of and plicated to the
shape of the segmental mastectomy defect (Figs. 19-6, A and B and see Fig. 19-5, B)
◆ Alternatively, if there is no skin defect, the skin island of the fl ap can be de-epithelialized
and placed underlying the native breast skin to provide additional soft tissue coverage (the
de-epithelialized skin will not atrophy, like the LD muscle; Figs. 19-6, C and D)
◆ A tension-free inset of the skin island is then performed over closed-suction drains.
Step 4. Postoperative Care
◆ After surgery, the patient is maintained with the ipsilateral arm abducted 30 degrees on a pillow
to avoid compression of the vascular pedicle along its transaxillary course. The fl ap is monitored
during the hospitalization for color, temperature, and capillary refi ll.
◆ As the operative site heals, the fl ap tissue integrates into the breast parenchyma (Figs. 19-6, E
and F). The LD muscle continues to atrophy over the next year or so.
Step 5. Pearls and Pitfalls
◆ The skin island should be kept small (minimizing the tension of closure results in a more
cosmetically acceptable scar) and concealed (patients can wear more revealing apparel).
◆ Remember to transect the TD nerve to avoid LD muscle contraction during daily activities.
◆ Premature drain removal confers a signifi cant risk for seroma formation at the donor site.
◆ Do not compress the vascular pedicle as it traverses through the tunnel to the defect in the
breast.
◆ After insetting the fl ap, abduct the ipsilateral extremity to ensure this motion does not place
undue tension on the vascular pedicle.
◆ When planning an LD fl ap after a previous axillary dissection, muscle function is tested (patient
extends her shoulders while pushing into hips to contract the LD muscle) to confi rm the
vascular pedicle is intact (the TD nerve lies adjacent to the TD vessels; the assumption is that
if nerve is intact, so are vessels). Previous TD vessel injury could preclude fl ap transfer.

Chapter 19 • Tissue Breast Reconstruction 283
A
B
C
D
Figure 19-6
E
F

284 Section IV • Mastectomy
B. Latissimus Dorsi Flap with Breast Implant for
Total Breast Reconstruction after Mastectomy
Step 1. Surgical Anatomy
◆ See Figure 19-1.
Step 2. Preoperative Considerations
◆ An LD fl ap with an implant is ideal to reconstruct a total breast defect in a thin patient who
does not require radiation therapy.
◆ This method of reconstruction is favored in patients with low body mass indexes and insuffi cient
abdominal tissue for a lower abdominal fl ap.
◆ An LD fl ap is also useful in patients who have undergone a previous abdominal surgery that
precludes the use of a lower abdominal fl ap or in those who are obese.
◆ Compared with a lower abdominal fl ap, an LD fl ap has the advantages of shorter operative
time, a quicker recovery, and no requirement for microsurgery.
◆ The use of an LD fl ap for bilateral reconstruction also has the advantage of not requiring that
both breasts be reconstructed simultaneously, as in the case of lower abdominal fl aps.
◆ The decision to proceed with a reconstruction using an LD fl ap plus a breast implant must be
based on many factors, including the breast pathology, clinical stage, and the need for adjuvant
radiation therapy; if the latter is required, a delayed approach to breast reconstruction is pre-
ferred to minimize complications and improve the overall cosmetic outcome.
◆ An LD fl ap reconstruction is limited by the amount of skin available to restore a large mastec-
tomy skin defect. With delayed breast reconstruction, the skin requirement often exceeds that
available from the LD fl ap because of the need to primarily close the donor site.
◆ The nipple-areolar defect that results from a skin-sparing mastectomy provides the ideal oppor-
tunity to minimize donor site morbidity with an LD fl ap.
◆ In patients who have had prior axillary surgery, it is critical to assess the motor function of the
LD muscle as a potential indicator of an intact TD pedicle. Preoperative Doppler ultrasonogra-
phy can be performed to evaluate blood fl ow in the TD pedicle.
◆ In unilateral LD reconstruction, the contralateral breast must be evaluated because it is ideal to
have an implant in this breast as well to optimize symmetry. This usually is done as a contra-
lateral mastopexy with breast implant augmentation.
◆ An advantage of the LD fl ap plus an implant is that it enables the reconstructive surgeon to
match the breast tissue in the previously augmented contralateral breast. The LD serves as the
breast tissue and the use of breast implants in both breasts tends to result in a symmetric
appearance (Fig. 19-7).

Chapter 19 • Tissue Breast Reconstruction 285
A
B
Figure 19-7

286 Section IV • Mastectomy
Step 3. Operative Steps
1. Preoperative Markings
◆ The patient is marked preoperatively as described earlier (see Fig. 19-3).
◆ If the breast is absent, such as in a delayed reconstruction, the inframammary fold and superior
breast border are transposed from the contralateral normal breast.
◆ The skin island is usually positioned centrally in the breast in the vicinity of the nipple-areolar
complex.
◆ The location of the fl ap skin island on the back overlying the LD is checked to ensure it will
allow for an adequate arc of rotation to the breast defect. The skin island is oriented in line
with the patient’s bra strap so that donor scar closure can be concealed (Fig. 19-8).
2. Intraoperative Patient Positioning
◆ The patient is positioned in the lateral decubitus position for fl ap harvest and donor site closure.
Flap insetting is performed with the patient supine and then upright, with the upper extremities
abducted 90 degrees and padded to avoid injury to the shoulder and brachial plexus.
◆ When immediate reconstruction is performed at the time of mastectomy, the patient remains
in the supine position to initiate the dissection of the TD vessels before being repositioned to
the lateral decubitus position to perform the fl ap harvest.
◆ Before the patient is repositioned, the mastectomy defect is temporarily closed and covered with
a plastic occlusive dressing.
3. Flap Harvest
◆ The mastectomy defect is assessed and a template of the skin defect is created to aid in design-
ing the skin island of the fl ap (see Fig. 19-4).
◆ As discussed for the harvest of the LD fl ap for repair of a segmental mastectomy defect, the
skin island is incised, the anterior aspect of the muscle is freed from the overlying skin and
subcutaneous tissue, and the posterior muscle dissection is initiated anteriorly between the
anterior border of the LD and the underlying SA. The dissection then proceeds from inferior
to superior, with meticulous dissection of the vascular pedicle in the axilla. After completing
the fl ap dissection, the fl ap is passed through the axilla into the mastectomy defect to allow for
closure of the back wound (Figs. 19-9 and 19-10).

Chapter 19 • Tissue Breast Reconstruction 287
Figure 19-8
Flap
transposition
Location for implant
Figure 19-9
Figure 19-10

288 Section IV • Mastectomy
4. Flap Insetting
◆ A subpectoral pocket is developed to allow placement of the implant in the subpectoral plane.
This creates a smooth contour in the upper pole and minimizes the prominence of the breast
implant superiorly.
◆ The LD fl ap (inferior border of muscle) is then inset with a 3-0 absorbable suture along the
superior and medial border of the breast.
◆ Next, a disposable breast implant sizer is placed behind the prepared submuscular (pectoralis
major and LD muscles) pocket (Fig. 19-11).
◆ The LD muscle is then inset to the lateral chest wall, defi ning the lateral edge of the recon-
structed breast.
◆ The implant sizer is injected with saline to the desired volume and the patient is placed in the
sitting position. The shape, projection, contour, and location of the reconstructed breast are
compared with the contralateral breast.
◆ Modifi cations to the fl ap inset are made as needed and the implant sizer is exchanged for a
permanent breast implant. The remaining inferior muscle fl ap is allowed to drape over the lower
pole and conform to the previously defi ned inframammary fold. The skin island is inset with
a subcutaneous layer of 3-0 absorbable sutures and a running layer of 4-0 absorbable sutures
for intradermal closure (Fig. 19-12).
Step 4. Postoperative Care
◆ After surgery, the patient is maintained with the ipsilateral arm abducted 30 degrees on a pillow
to avoid compression of the pedicle along its transaxillary course.
◆ The patient wears a surgical bra and the visible portion of the fl ap is used to assess skin perfu-
sion. The bra should be loose to avoid compression of the vascular pedicle and used mainly to
secure fl uffed gauze in the lateral aspect of the reconstructed breast to assist in maintaining the
position of the implant and avoid axillary migration.
◆ After surgery, trained staff assess the fl ap’s color, temperature, and capillary refi ll.
◆ As seen in this patient 18 months after reconstruction, the LD continues to atrophy over time
and the underlying implant plays a more prominent role in the reconstruction (Fig. 19-13).
Step 5. Pearls and Pitfalls
◆ Confi rm TD pedicle continuity before committing to fl ap harvest.
◆ Place the breast implant under both the pectoralis major and LD muscles to minimize implant
rippling in the superior and medial aspects of the reconstructed breast.
◆ Avoid donor site seroma formation with prolonged use of closed-suction drains.

Chapter 19 • Tissue Breast Reconstruction 289
Pectoralis minor muscle
Pectoralis major muscle
Pedicled latissimus flap
Implant placed in
submuscular plane
Figure 19-11
Figure 19-12
A
B
Figure 19-13

290 Section IV • Mastectomy
C. Lower Abdominal Flaps: Transverse Rectus
Abdominis Myocutaneous (TRAM) Flap and Deep
Inferior Epigastric Perforator Flap
Step 1. Surgical Anatomy
◆ The superior epigastric artery and vein are the terminal branches of the internal mammary
system (Fig. 19-14).
◆ The deep inferior epigastric artery and vein that originate from the iliac vessels provide the
dominant blood supply to the tissues of the lower abdominal wall. These vessels are connected
through a variable number of intramuscular “choke anastomoses” (connecting branches) in the
rectus abdominis muscle at the umbilical region that allow for perfusion of the lower abdominal
tissue through the superior epigastric system. This provides the basis of perfusion of the pedi-
cled TRAM fl ap.
◆ The deep inferior epigastric vessels originate from the iliac vessels (inguinal region) and
enter the rectus muscle inferolaterally after giving off a medial branch to the rectus muscle
(see Fig. 19-14).
◆ The vessels then travel along the undersurface of the muscle until they enter the substance of
the muscle, giving off perforating branches that pierce the anterior rectus sheath to supply the
overlying skin and subcutaneous tissue of the lower abdominal region (Fig. 19-15).
◆ Similarly, the medial branch to the rectus muscle that originated from the main trunk of the
deep inferior epigastric vessels supplies the medial row of perforating blood vessels. These
perforating vessels provide blood fl ow to the subcutaneous tissue and skin of the lower abdomi-
nal fl ap (see Fig. 19-15).

Chapter 19 • Tissue Breast Reconstruction 291
Intramuscular
collateral network
“choke vessels”
Superior
epigastric artery
Deep inferior
epigastric artery
Figure 19-14
Superior
epigastric artery
and vein
Intercostal blood
supply
Rectus
abdominis
muscle (cut)
Perforators to
skin paddle
Deep inferior
epigastric vessels
Figure 19-15

292 Section IV • Mastectomy
◆ Vascular supply of a unilateral TRAM fl ap is classifi ed into four zones on the basis of perfusion
to the overlying skin and subcutaneous tissues: zone 1 overlies the ipsilateral rectus sheath;
zone 2 is lateral to and on the same side of the abdominal wall as zone 1; zone 3 overlies the
contralateral rectus sheath across the midline; and zone 4 is lateral to and on the same side as
zone 3 (Fig. 19-16).
◆ When either pedicled or free TRAM fl aps are transferred to the chest wall, zone 1 has the best
perfusion and zone 4 the worst. However, because of variable watershed regions of blood supply
to the lower abdomen, these zones of perfusion can differ from patient to patient.
1. Variations of Lower Abdominal Flaps
◆ The lower abdominal adipose tissue can be used to reconstruct a breast in several different
ways. Tissue can be transferred as a pedicled fl ap (Fig. 19-17, A), in which the blood supply
to the fl ap remains attached to the rectus abdominis muscle, or as a microvascular free fl ap, in
which the fl ap is completely freed from the deep inferior epigastric vessels and then anasto-
mosed to recipient vessels located on the chest wall (most commonly, internal mammary or
TD artery and vein) using microsurgical techniques.
◆ A pedicled TRAM fl ap requires harvest of the entire rectus abdominis muscle to include blood
supply from the superior epigastric artery and vein. The advantage of this fl ap design is that it
does not require microsurgical skills; however, there can be signifi cant donor site morbidity
owing to the need to extensively repair the abdominal wall after harvest of the fl ap. The blood
supply to the pedicle is not the dominant supply to the lower abdominal adipose tissue (deep
inferior epigastric vessels) and depends on the number of choke anastomoses (connections) at
the umbilical region, which can alter the perfusion to the fl ap and result in higher rates of fat
necrosis than in microsurgical TRAM fl aps (see Fig. 19-14).
◆ Although a microsurgical TRAM fl ap requires expertise in microsurgery, it requires less rectus
abdominis muscle (only the lower one third) than a pedicled TRAM fl ap because it does not
need to remain attached to the rectus muscle while being tunneled to the chest wall. A variant
of the free TRAM fl ap that preserves a lateral or medial strip of rectus muscle, the so-called
muscle-sparing microvascular TRAM fl ap, further reduces the amount of rectus muscle that
needs to be harvested with the fl ap while providing a similar degree of perfusion to the fl ap
(Fig. 19-17, B).
◆ A deep inferior epigastric perforator (DIEP) fl ap (Fig. 19-17, C), which comes from the same
area as a TRAM fl ap, involves harvesting only the perforating blood vessels that branch off from
the deep inferior epigastric vessels (located in the rectus abdominis muscle) and perforate the
lower abdominal adipose tissue. The DIEP fl ap avoids having to harvest any rectus muscle or
fascia with the lower abdominal tissue fl ap because the perforating blood vessels, as well as the
deep inferior epigastric vessels, are dissected free from the rectus abdominis using a longitudinal
muscle-splitting incision.

Chapter 19 • Tissue Breast Reconstruction 293
4
1
2
3
Rectus
abdominis
muscle
Figure 19-16
B. Muscle-sparing TRAM flap
C. DIEP flap
A. Pedicled TRAM flap
Figure 19-17

294 Section IV • Mastectomy
Step 2. Preoperative Considerations
◆ Microsurgical free tissue transfer has enabled creation of reconstructed breasts with an optimal
blood supply and resultant decrease in postoperative fat necrosis of the fl ap. The lower abdomi-
nal donor site offers abundant skin and subcutaneous tissue of a texture that replicates the
tissue quality of the breast.
◆ The decision to proceed with autologous breast reconstruction must be based on many factors,
including the patient’s physiologic age, breast pathology, clinical stage, and the potential need
for adjuvant radiation therapy. Although there are no clearly defi ned age criteria for free tissue
transfer, patients with signifi cant comorbidities may not be optimal candidates for this approach.
If the need for adjuvant radiation therapy is anticipated, a delayed approach to breast recon-
struction is preferred to minimize complications and improve the eventual cosmetic outcome
of the breast reconstruction.
◆ In unilateral autologous tissue reconstruction, the contralateral breast should have adequate
volume to match the free autologous tissue transfer because the use of a unilateral breast implant
can lead to asymmetry between the breasts, with gravitational effects predominantly leading to
ptosis of the autologous reconstructed breast. However, the need for a contralateral mastopexy
or reduction mammoplasty is not uncommon in many patients undergoing unilateral autolo-
gous tissue reconstruction.
◆ There has been an increasing trend away from using the TD vessels and toward the internal
mammary vessels as recipient vessels for an immediate microvascular tissue transfer, which
allows for reoperative axillary surgery to be performed without concern for injury to the vascular
pedicle. This would be important in the clinical scenario of an axillary sentinel lymph node
that was negative intraoperatively but was subsequently found to be positive on permanent
pathology.
Step 3. Operative Steps
1. Preoperative Markings
◆ The patient is marked preoperatively in the standing position (Fig. 19-18).
◆ The lower abdomen fl ap is outlined as an ellipse extending from the suprapubic area inferiorly,
to the anterior superior iliac spine laterally, and to the supraumbilical area superiorly.
◆ The patient is positioned supine on the examination table with the knees fl exed, and the borders
of the lower abdominal fl ap are approximated to assess the resultant tension on the donor site
closure.
◆ The markings are evaluated for symmetry at a distance and preoperative photographs are
obtained to assist in fi nalizing the operative plan.

Chapter 19 • Tissue Breast Reconstruction 295
Figure 19-18

296 Section IV • Mastectomy
2. Intraoperative Patient Positioning
◆ The patient is positioned supine with the upper extremities abducted to 90 degrees and
padded.
◆ Semi-Fowler positioning is used to decrease the tension of the abdominal donor site closure.
◆ Care is taken to secure the patient’s head, endotracheal tube, and arms in anticipation of sitting
the patient in the upright position during the insetting of the reconstructed breast.
3. Harvest of the Lower Abdominal Flap
◆ The inferior lower abdominal markings are incised initially and dissection is carried down to
the anterior fascia of the abdominal wall (anterior fascial layer of rectus abdominis and external
oblique muscles). The superfi cial inferior epigastric (SIE) veins are preserved along the lower
border of the fl ap to serve as potential donor veins (microsurgical anastomoses) for the fl ap if
it exhibits signs of venous congestion after transfer to the chest wall. If a large-caliber SIE artery
is found along with an SIE vein, consideration can be given to perform an SIE artery fl ap.
The superior lower incision is then taken down to the anterior rectus sheath and external
oblique fascia. The umbilicus is then dissected away from the fl ap with a wide vascular cuff
(Fig. 19-19).
◆ The dissection of the undersurface of the fl ap is then performed from lateral to medial
toward the anterior rectus sheath until the lateral row of perforators from the underlying rectus
abdominis muscle is identifi ed bilaterally. If a hemi (one-half) lower abdominal fl ap is planned,
the fl ap is incised in the midline and the medial row of perforators is identifi ed. If the tissue
across the midline is to be included with the fl ap (depends on volume needs of the reconstructed
breast), the medial perforators are dissected by freeing the adipose tissue from the midline fascia
without transection of the overlying skin and adipose tissue. All perforating blood vessels from
both rectus muscles are subsequently evaluated using Doppler ultrasonography for their loca-
tion, luminal diameter, and fl ow.
◆ The selected perforators are then assessed by placing Acland microsurgical occluding clamps
on the perforators not selected for inclusion with the fl ap to be certain that the selected
perforator(s) will provide adequate perfusion to the fl ap. Once the perforators have been appro-
priately selected, the fl ap harvest can proceed either as a fascia-sparing, pedicled TRAM fl ap, a
fascia-sparing microvascular TRAM fl ap, a fascia-sparing, muscle-sparing microvascular TRAM
fl ap, or a DIEP fl ap, depending on the volume of tissue required, perforator anatomy, and the
surgeon’s preference.
4. Harvest of Pedicled TRAM Flap
◆ The anterior rectus fascia is incised around the previously dissected perforators to spare as
much fascia as possible. The rectus abdominis muscle is then freed from its encasement in the
rectus sheath with careful dissection of the muscle from the tendinous inscriptions. The deep
inferior epigastric pedicle is identifi ed, dissected, and ligated at its origin from the iliac vessels
(Fig. 19-20).

Chapter 19 • Tissue Breast Reconstruction 297
Preserved superficial
epigastric vein
Perforators
Ligated
perforators
Deep inferior
epigastric vessels
Figure 19-19
Ligated deep inferior
epigastric vessels
Lateral and medial row
of perforators preserved
Superior epigastric
blood supply preserved
Figure 19-20

298 Section IV • Mastectomy
◆ Preserving adequate length of these vessels is imperative should additional lateral supply or
venous drainage from the fl ap be required after transfer to the chest wall.
◆ The anterior rectus sheath is then incised superiorly along the muscle length to the costal
margin. Next, the rectus muscle is further freed from the rectus sheath and divided inferiorly
below the entry point of the deep inferior epigastric vessels (Fig. 19-21, A).
◆ A subcutaneous tunnel is then created through the superomedial aspect of the abdominal donor
site to allow transfer of the fl ap to the mastectomy defect without undue tension or constriction.
The fl ap is then delivered to the mastectomy defect and shaped into the reconstructed breast
(Fig. 19-21, B).
5. Harvest of Microvascular TRAM Flap
◆ Once the perforator anatomy has been delineated, the decision as to whether to perform a
microvascular TRAM fl ap or a DIEP fl ap can be made.
◆ The decision to perform a microvascular TRAM fl ap as opposed to a DIEP fl ap is based on the
fi nding of inadequate perforators (small size, few in number, or poor fl ow or perfusion to the
fl ap). As with a pedicled TRAM fl ap, multiple perforators are harvested with a microvascular
TRAM fl ap, including perforators from both the medial and lateral rows.
◆ In a manner similar to that described for a pedicled TRAM fl ap, the anterior rectus fascia is
incised around the selected perforators in order to spare anterior rectus sheath fascia. At the
inferolateral aspect of the rectus abdominis muscle, the deep inferior epigastric vascular pedicle
is identifi ed and dissected toward its origin from the iliac artery and vein (Fig.19-22, A). Next,
the rectus muscle is divided at the superior and inferior margin. The deep inferior epigastric
vascular pedicle is then divided at its origin from the external iliac vessels. The fl ap is then
completely freed from the body and positioned on the chest wall for microsurgical anastomosis
to the already prepared recipient vessels (Fig. 19-22, B).

Chapter 19 • Tissue Breast Reconstruction 299
A. Flap transposed into mastectomy defect
B. Flap inset
Figure 19-21
Full width of
rectus abdominis
incorporated into flap
Dissection of deep
inferior epigastric pedicle
A
B
Figure 19-22

300 Section IV • Mastectomy
Case Example: Free TRAM Flap
◆ A 43-year-old woman presented with left-sided ductal carcinoma in situ (Figs. 19-23, A). Pre-
operative markings were made for lower abdominal TRAM fl ap (Fig. 19-23, B). The left-sided
internal mammary perforating artery and vein through the third intercostal space were used as
recipient vessels, instead of the internal mammary vessels proper. Microsurgical anastomoses
were done of the left internal mammary artery perforator to the right deep inferior epigastric
artery and the left internal mammary perforating vein to the right deep inferior epigastric vein
(Fig. 19-23, C). The anterior rectus sheath fascia, which was excised with the harvested TRAM
fl ap, was replaced with an inlay allograft of human cadaver dermis. Figure 19-23, D shows the
patient 2 years after reconstruction of the left breast with a microvascular TRAM fl ap.

Chapter 19 • Tissue Breast Reconstruction 301
A
B
Figure 19-23
C
D

302 Section IV • Mastectomy
6. Harvest of Muscle-Sparing TRAM Flap
◆ Once the perforator anatomy has been established, a muscle-sparing TRAM fl ap can be designed.
If medial-row perforators are selected, the lateral muscle can be spared with its intercostal
neurovascular supply left intact. If the lateral row of perforators is selected, the medial muscle
can be preserved. The intercostal branches enter the rectus muscle laterally, contributing
sensory and motor innervation as well as vascular branches that anastomose with the deep
inferior epigastric vessels. In muscle-sparing TRAM fl aps, preservation of the intercostal nerves
maintains the function of the rectus muscle that remains after harvest of the fl ap (Fig. 19-24).
As with a non–muscle-sparing TRAM fl ap, the harvest of the anterior rectus fascia is minimized
by incising medially and laterally to incorporate only the selected perforators, thus sparing as
much fascia as possible for closure.

Chapter 19 • Tissue Breast Reconstruction 303
Muscle
incorporated
into flap
Muscle
preserved
Portion of muscle surrounding perforators is incorporated into flap design
Figure 19-24

304 Section IV • Mastectomy
7. Harvest of DIEP Flap
◆ Once the perforator anatomy has been established and adequate perforators (large size, good
fl ow, and adequate perfusion to fl ap) identifi ed, a DIEP fl ap can be designed.
◆ DIEP fl aps can be designed with one or multiple perforators depending on intraoperative assess-
ment of fl ap perfusion and clustering of perforator location. Each selected perforator is meticu-
lously dissected, sparing the anterior rectus sheath with careful intramuscular dissection
(Fig. 19-25, A).
◆ Care is taken not to denervate the rectus abdominis muscle. The intramuscular dissection is
performed to trace the perforating artery and vein back to the deep inferior epigastric artery
and vein. These vessels, which will serve as the vascular pedicle to the fl ap, are dissected to
their origin from the external iliac vessels to obtain a pedicle of adequate length and caliber for
the microvascular anastomosis (Fig. 19-25, B).

Chapter 19 • Tissue Breast Reconstruction 305
No muscle
included in flap
Rectus abdominis
muscle preserved
Deep inferior
epigasric vessels
Superficial inferior
epigastric arteries
A
B
Figure 19-25