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

Chapter 19 • Tissue Breast Reconstruction 307
A
B
C
D
E
Figure 19-26

308 Section IV • Mastectomy
◆ A 31-year-old woman with angiosarcoma of the left breast underwent preoperative radiation
therapy before mastectomy and immediate breast reconstruction (Figs. 19-27, A and B). Pre-
operative markings were made for a lower abdominal DIEP fl ap, just as for a TRAM fl ap
(Fig. 19-27, C). Figure 19-27, D shows an in situ view of the multiple perforators supplying
the fl ap from the deep inferior epigastric vessels. The fl ap after harvest (Fig. 19-27, E). Figures
19-27, F and G show the patient 1 year after reconstruction of the left breast with a right-sided
DIEP fl ap.

Chapter 19 • Tissue Breast Reconstruction 309
A
B
C
D
Figure 19-27
E
F
G

310 Section IV • Mastectomy
8. Preparation of Recipient Vessels for Microvascular Anastomosis
◆ The internal mammary vessels are preferred over the TD vessels as recipients for microvascular
breast reconstruction. The internal mammary vessels have the advantage of allowing fl ap inset
and positioning more medially on the chest wall, and are not involved in the operative fi eld in
the event the patient requires additional axillary nodal removal because of a positive sentinel
lymph node on the permanent pathology.
◆ The internal mammary vessels are usually accessed through the third intercostal space.
◆ The overlying pectoralis major is divided along its fi bers and the perichondrium overlying the
costal cartilage is incised, enabling the costal cartilage to be separated from the posterior
perichondrium.
◆ Next, a lateral incision is made through the cartilage and the medial sternocostal ligaments are
disrupted, allowing for removal of the cartilage. Meticulous dissection is then performed to
dissect the posterior perichondrium away from the internal mammary vessels, with special care
taken to ligate the intercostal and cutaneous branches.
◆ When there is only a single internal mammary vein (IMV), it is usually located medial to the
internal mammary artery (IMA). The left IMV is often smaller than the right IMV. When two
IMVs are present, the second vein is usually positioned lateral to the IMA (Fig. 19-28).
◆ The internal mammary vessels are then dissected from each other and the surrounding adven-
titial tissue in preparation for microvascular anastomosis. Great care must be taken in the previ-
ously irradiated patient.
9. Flap Transfer and Revascularization
◆ Once the fl ap is evaluated for in situ perfusion, the pedicle is clamped with Acland clamps and
ligated, and the deep inferior epigastric artery is irrigated with heparinized saline until clear
effl uent returns through the vein. The fl ap is then temporarily secured to the chest wall.
◆ With the aid of an operating microscope or surgical loupes, end-to-end microvascular anasto-
moses of the arteries (IMA to deep inferior epigastric artery) and veins (IMV to deep inferior
epigastric vein) are then performed, using 9.0 nylon suture. The 11th intercostal nerve is also
anastomosed to intercostal nerves on the chest wall with 10-0 nylon.
◆ Venous microvascular coupling devices or end-to-side microvascular anastomoses are some-
times used.
◆ On completion of the microsurgery, the Acland clamps are removed and perfusion to the fl ap
is reestablished. Careful inspection for patency and blood fl ow is performed by gross examina-
tion and hand-held Doppler ultrasound probe, and confi rmed by observing distal dermal bleed-
ing (Fig. 19-29).

Chapter 19 • Tissue Breast Reconstruction 311
Third costal
cartilage removed
Internal mammary
vessels exposed
Figure 19-28
A
B
C
Figure 19-29

312 Section IV • Mastectomy
10. Flap Insetting
◆ The fl ap is then introduced into the mastectomy defect, with care taken to position the vascular
pedicle without kinking or compression.
◆ For unilateral breast reconstruction, the fl ap can be based on either the ipsilateral or contralat-
eral vascular pedicle. If the fl ap is based on the contralateral vascular pedicle, the fl ap is inset
vertically to allow the areas of maximal blood supply (zones 1 and 2) to be positioned in the
medial and inferior aspects of the reconstructed breast and the lesser-perfused region (zone 3)
to be positioned either underneath zone 1 (increased lower pole projection) or in the lateral
aspect (increased lateral breast and axillary volume, especially pertinent to patients who required
a complete nodal dissection with axillary irradiation) of the reconstructed breast (Figs. 19-30
and 19-31).

Chapter 19 • Tissue Breast Reconstruction 313
Figure 19-30
A
B
Figure 19-31

314 Section IV • Mastectomy
◆ Alternatively, if a horizontal inset is preferred to reconstruct a wider-shaped breast, the lower
abdominal fl ap should be based on the ipsilateral vascular pedicle and rotated 180 degrees to
inset (Figs. 19-32 and 19-33). With the horizontal orientation, there can be some soft tissue
defi ciency in the superior aspect of the reconstructed breast.
◆ With either orientation, the fl ap can be plicated to maximize projection in the lower pole of
the reconstructed breast. The mastectomy fl aps are then evaluated and trimmed as needed. The
skin island of the fl ap is then marked to fi t the mastectomy skin defect, and the remaining skin
is de-epithelialized.
◆ Drains are placed superiorly and inferiorly in the mastectomy pocket, with care taken to avoid
placing the drains adjacent to the vascular pedicle.
◆ The fl ap is then inset with 3-0 absorbable deep dermal inverted sutures; a running intradermal
4-0 absorbable suture completes the skin closure.
◆ A hand-held Doppler ultrasound probe is used to locate the transcutaneous arterial and venous
signals for postoperative monitoring.

Chapter 19 • Tissue Breast Reconstruction 315
Figure 19-32
A
B
Figure 19-33

316 Section IV • Mastectomy
11. Closure of the Abdominal Donor Site
◆ Closure of the anterior rectus sheath fascial defect is accomplished with interrupted or running
no. 1 nonabsorbable sutures.
◆ Care is taken to incorporate the cut edge of the aponeurosis of both the internal and external
oblique muscles into the closure. This prevents musculofascial laxity that can later result in
bulge formation.
◆ If the fascial defect can be closed primarily, the contralateral aspect of the lower abdominal wall
usually will need to be plicated in order to centralize the umbilicus to the midline of the
abdominal wall. The contralateral plication can be diffi cult in this situation because the fascia
is already tight from closing the primary defect and can result in tearing of the fascia, which
may weaken its integrity.
◆ If there is tension and primary fascial closure is not feasible, a synthetic mesh inlay or allograft
can be used to replace the resected fascia of the anterior rectus sheath (Figs. 19-34 and
19-35).
◆ Patients who undergo breast reconstruction using a DIEP fl ap can usually have primary tension-
free repair of the fascial incision without plication of the contralateral lower abdominal wall
because the umbilical position is maintained in the midline (Figs. 19-36 and 19-37).
◆ The upper abdominal skin fl ap is then minimally undermined to the costal margin to allow for
a tension-free skin closure. This also provides access to plicate the upper midline of the abdomi-
nal wall, which maintains a smooth contour to the abdominal wall.
◆ Skin closure along the lower abdominal crease is then performed after placement of drains.
◆ The Scarpa fascial layer is closed with 2-0 absorbable sutures to minimize tension on the skin
closure.
◆ The skin layer is closed with 3-0 absorbable subcuticular inverted sutures; a running intrader-
mal 4-0 absorbable suture is used for skin-edge approximation.
◆ The umbilical stalk, which remains attached to the abdominal wall throughout the fl ap harvest,
is then delivered through the abdominal skin fl ap and inset into its anatomic position with
absorbable sutures.
Step 4. Postoperative Care
◆ The patient is maintained in the semi-Fowler position to minimize tension on the abdominal
skin closure. The patient wears a loose-fi tting surgical bra.
◆ The visible portion of the fl ap is assessed for skin perfusion using a hand-held Doppler ultra-
sound probe.
◆ The fl ap is also monitored hourly for color, temperature, and capillary refi ll by trained staff.
◆ If at any time there is an interruption of vascular fl ow, either arterial or venous, the patient is
returned to the operating room for emergent reexploration.

Chapter 19 • Tissue Breast Reconstruction 317
A
B
Figure 19-34
Figure 19-35
Primary fascial closure of abdominal donor site
Figure 19-36
Figure 19-37

318 Section IV • Mastectomy
Step 5. Pearls and Pitfalls
◆ For a pedicled TRAM fl ap, be sure to create a tunnel of adequate width to avoid compression
of pedicle. After fl ap transfer, decompress the deep inferior epigastric vein and anastomose for
venous supercharging as needed.
◆ The left IMV is smaller than the right IMV.
◆ Be meticulous when dissecting irradiated vessels.
◆ With DIEP fl aps, preserve the SIE vein in the event the fl ap becomes venous congested and
requires supercharging to provide additional venous drainage.
◆ Incorporate both the internal and external oblique muscle aponeuroses during abdominal
closure to avoid bulge formation.
D. Gluteal Artery Perforator (GAP) Flap
Step 1. Surgical Anatomy
◆ Figure 19-38 shows the anatomic considerations for a gluteal fl ap.
Step 2. Preoperative Considerations
◆ The ideal candidate for a gluteal fl ap is a patient who does not want to pursue implant recon-
struction and does not have adequate abdominal tissue.
◆ Thin patients must have the appropriate body habitus to allow for suffi cient tissue harvest from
the gluteal region.
◆ Obese patients who usually are not considered candidates for an abdominal fl ap are also usually
not eligible for a gluteal fl ap.
◆ The blood supply is a single perforator from the superior or inferior gluteal vessel, depending
on where the selected perforator enters the fl ap.
◆ The redesigned gluteal fl ap shown in the case example allows for the reconstruction of a larger
and better-contoured breast than with the standard elliptical fl ap.

Chapter 19 • Tissue Breast Reconstruction 319
Great
trochanter
Posterior superior
iliac spine
Superior gluteal
artery perforator
Figure 19-38

320 Section IV • Mastectomy
Step 3. Operative Steps
1. Preoperative Markings
◆ The patient is marked in the prone position. A line is drawn between the posterior superior
iliac spine and the greater trochanter. The gluteal artery is found approximately one third of
the distance from the posterior iliac spine along this line (Fig. 19-39). Cutaneous perforators
can be identifi ed with a hand-held Doppler ultrasound probe along this line. A curvilinear skin
island is outlined within the vascular territory of the identifi ed perforators. The fl ap is oriented
so that the superior and medial aspects of the breast fl ap correspond to the medial and
inferior aspects, respectively, of the gluteal donor site. This orientation allows the regions of
maximal blood supply to correspond to the more visible aspects of the reconstructed breast
(Fig. 19-40).
2. Intraoperative Patient Positioning
◆ There are two position changes required during the procedure. The patient is initially positioned
supine for the dissection of the internal mammary recipient vessels and then again later after
the fl ap harvest for the microsurgery and fl ap insetting.
◆ After preparation of the internal mammary vessels, which serve as the recipient vessels for
gluteal fl aps, the patient is repositioned to the prone position for fl ap harvest.
3. Flap Harvest
◆ The redesigned gluteal fl ap is harvested from the contralateral buttock. The patient is positioned
in the prone position for harvest, not the corkscrew position, to avoid back-related injury. The
skin island of the fl ap is incised down to the gluteal fascia; however, in the superolateral aspect
of the fl ap on the buttock, only the adipose tissue located below the Scarpa fascial layer is har-
vested to create a circumferential fl ap with regard to blood supply. The circumferential blood
supply allows for adequate perfusion of the curvilinear skin island.
◆ Next, the deep gluteal fascia is identifi ed and incised. Subfascial dissection begins at the infero-
medial aspect of the fl ap, which allows for easier identifi cation of the perforators as they pene-
trate the gluteal muscles. Usually one to three perforators can be identifi ed; the determination
of which perforator to use is based on caliber and location relative to the skin island. The entire
gluteal fl ap can be raised on a single perforator of adequate caliber. Perforators positioned later-
ally from the fl ap’s long axis will produce a longer vascular pedicle.
◆ Once the perforator is selected, it is traced proximally. Meticulous intramuscular dissection is
carried out, with care taken to ligate all intramuscular side branches. Extended proximal dis-
section on the pedicle is carried out to obtain an artery of appropriate caliber for anastomosis
with the IMA. Subsequent dissection is complicated by a dense venous network that requires
tedious vascular control. Once an adequate pedicle caliber is obtained, the fl ap is ready for
transfer (Fig. 19-41). The fl ap is evaluated for in situ perfusion while it is still attached to its
native vascular supply in the buttock.

Chapter 19 • Tissue Breast Reconstruction 321
A
S-GAP flap
Superior
gluteal artery
Gluteus maximus
muscle split
Gluteus medius
muscle
B
Figure 19-39
Figure 19-41
Great
trochanter
Posterior superior
iliac spine
Superior gluteal
artery perforator
Figure 19-40

322 Section IV • Mastectomy
◆ Next, the pedicle is ligated and the deep gluteal artery is irrigated with heparinized saline until
there is clear return through the vein. The fl ap is then placed on cold ischemia during donor
site closure and repositioning of the patient (Fig. 19-42).
4. Closure of Donor Site
◆ The gluteal donor site is closed in layers over suction drains. The Scarpa fascial layer is closed
with 2-0 absorbable sutures to alleviate any tension on the skin closure. The skin layer is closed
with 3-0 absorbable subcuticular inverted sutures, and a running intradermal 4-0 suture is used
for skin closure.
5. Flap Transfer and Revascularization
◆ Next, the patient is positioned supine on the operating table.
◆ The fl ap is then transferred and secured to the chest wall. Vascular control of the internal
mammary vessels is obtained with Acland clamps. The donor and recipient vessels are prepared
for microsurgery and sewn with the aid of the operating microscope or surgical loupes. The
microvascular anastomoses between the gluteal artery and IMA and the gluteal vein and IMV
are usually performed in an end-to-end fashion with 9-0 nylon (Fig. 19-43). On completion,
the Acland clamps are removed and the anastomoses are inspected for patency and blood fl ow.
Adequate fl ap reperfusion is confi rmed by observing distal dermal bleeding.

Chapter 19 • Tissue Breast Reconstruction 323
A
B
Figure 19-42
Anastomosis of superior
gluteal artery to internal
mammary artery
Figure 19-43

324 Section IV • Mastectomy
6. Flap Insetting
◆ The fl ap is then introduced into the mastectomy defect, orienting the pedicle without torsion.
◆ The gluteal subcutaneous fat is more fi brodense than that of the lower abdominal wall. With
the standard elliptical fl ap, this can be problematic because of kinking of the perforator, but
with the redesigned fl ap, the shape is built into the design. As a result, it is not necessary to
shape the fl ap for inset. The fl ap requires only minimal plication to complete the shape of the
reconstructed breast.
◆ The mastectomy fl aps are then evaluated and trimmed as needed. The skin island of the fl ap
is marked to the dimension of the mastectomy skin defect and the remaining fl ap skin is de-
epithelialized. Drains are placed superiorly and inferiorly in the mastectomy pocket, away from
the pedicle. The fl ap is then inset with 3-0 absorbable deep dermal inverted sutures; a running
intradermal absorbable suture completes the epidermal closure. A hand-held Doppler ultra-
sound probe is used to locate transcutaneous arterial and venous signals, which are marked for
postoperative monitoring.
◆ Figure 19-44 shows preoperative and postoperative views of the reconstructed breast and the
donor site 3 months after revision.

Chapter 19 • Tissue Breast Reconstruction 325
A
C
D
Figure 19-44
B

326 Section IV • Mastectomy
Case Example
◆ A 26-year-old woman (Fig. 19-45, A) with a 32C breast size and minimal abdominal adipose
tissue and laxity (nulliparous) presented with right-sided breast cancer (stage IIA). A modifi ed
radical mastectomy and a delayed-immediate approach to breast reconstruction was planned
because she was considered preoperatively to require postmastectomy radiation therapy (PMRT).
After mastectomy a subpectoral, fully infl ated tissue expander (400 mL) was placed to preserve
the breast skin envelope. The tissue expander remained infl ated during the 6-week interval
between mastectomy and the start of PMRT.
◆ The expander was completely defl ated during PMRT (6 weeks) and reinfl ated (Fig. 19-45, B)
2 weeks after the completion of PMRT to the predefl ation volume (400 mL). The expander was
removed at the time of the redesigned gluteal artery perforator fl ap reconstruction.
◆ Figure 19-45, C shows an intraoperative view of the patient in prone position with the rede-
signed gluteal artery perforator fl ap design marked on the left buttock. The black curvilinear
line indicates the outline for the skin island. The red oval line indicates the sub-Scarpa fascial
layer superomedial extension and subcutaneous inferolateral extension of the fl ap. The red “X”
marks indicate audible Doppler signals at the preferred locations in the fl ap. The trochanter is
marked in black on the lateral hip.
◆ Figures 19-45, D and E show the fl ap after harvest.
◆ Figure 19-45, F shows the patient after being repositioned supine with the fl ap temporarily in
the axilla after completion of the microsurgery. The long pedicle length provided with the
redesigned gluteal artery perforator fl ap allows for the fl ap to be positioned within the axilla
during microsurgery. This makes the microsurgery easier because the thick gluteal fl ap does
not interfere with the delicate hand movements required. The longer pedicle also makes it pos-
sible to use other recipient vessels (e.g., the TD vessels) while still positioning the fl ap medially
on the chest wall.
◆ Positioning the perforator at the inferolateral aspect of the fl ap on the buttock (Fig. 19-45, G),
placing the perforator near the internal mammary vessels on the chest wall, and the extended
dissection of the gluteal vessels beyond the gluteal fascia all contribute to the long pedicle length.
As shown, the perforator is located along the inferomedial aspect of the reconstructed breast,
which avoids the full weight of the fl ap compressing the perforator against the underlying chest
wall.
◆ Figure 19-45, H shows the redesigned gluteal artery perforator fl ap on the chest wall during
insetting to create the breast form. The fl ap has been rotated 90 degrees counterclockwise from
its orientation on the contralateral buttock, but has not yet been placed in the breast skin
envelope. The superolateral border of the fl ap (buttock) has been rotated in a clockwise direc-
tion and plicated over the sub-Scarpa’s fascial layer to enhance the vertical dimension and
inferolateral aspect of the reconstructed breast. The superomedial aspect of the fl ap (buttock),
the portion of the fl ap that includes only the tissue below the Scarpa fascial layer, will be posi-
tioned in the axillary region of the reconstructed breast, where it will supplant the axillary
volume in this patient who underwent a level I and II axillary lymph node dissection as well
as axillary radiation.
◆ Figures 19-45, I and J show the patient 2 weeks after a skin-preserving, delayed right breast
reconstruction with a left-sided redesigned gluteal artery perforator fl ap.

Chapter 19 • Tissue Breast Reconstruction 327
A
B
C
D
E
F
Figure 19-45

328 Section IV • Mastectomy
Step 4. Postoperative Care
◆ The patient uses several pillows for sitting to avoid undue pressure on the gluteal closure, but
otherwise requires no specifi c bed positioning.
◆ The perfusion of the fl ap is assessed hourly, as previously indicated.
◆ The patient is maintained in a girdle to assist in recontouring the buttock region and to avoid
seroma formation. Drains are maintained for 2 to 3 weeks to minimize the risk of seroma for-
mation. Surgical revision of the donor site is deferred for 6 months to ensure suffi cient tissue
laxity to allow for advancement and de-epithelialization of the inferior skin fl ap underlying the
superior skin fl ap.
Step 5. Pearls and Pitfalls
◆ Continue the proximal dissection of the inferior or superior gluteal artery until a large-caliber
luminal diameter is available. A small arterial diameter signifi cantly complicates the microsur-
gery and carries a higher rate of failure for these fl aps.
◆ Avoid using a medially located perforator because this will limit the length of the donor vessels
and lead to tension on the vascular pedicle when the patient is in an upright position, with a
subsequently higher risk for fl ap failure.
◆ Avoid placing the patient in the corkscrew position to save time because this position for
extended periods may be associated with subsequent back-related problems.

Chapter 19 • Tissue Breast Reconstruction 329
G
H
I
J
Figure 19-45, cont’d

330 Section IV • Mastectomy
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Chapter 19 • Tissue Breast Reconstruction 331
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Step 1. Surgical Anatomy
◆ Once the assessment has been completed regarding tumor size and location, attention is turned
to the details of aesthetic qualities of the existing breasts, and the patient’s desires. Symmetry,
sensation, degree of ptosis, skin tone, stretch marks, and the like are all evaluated, noted, and
discussed with the patient and documented with photography.
◆ Markings are placed on the patient before surgery with the patient in the upright position.
Important anatomic landmarks include the following:
▲ Suprasternal notch
▲ Breast meridian
▲ Inframammary fold
▲ Superior areolar point (SAP)
▲ New SAP
▲ Distance to new SAP
◆ If the nipple–areolar complex (NAC) is to be preserved, it must be determined whether this
can be accomplished on a tissue pedicle or if the NAC will need to be transferred as a free graft.
If the new SAP is more than 10 to 11 cm from the existing SAP, the NAC will in many cases
need to be removed and transplanted as a free nipple graft (particularly if the tissue is dense
and fi rm). In the fatty, pendulous breast, the NAC tends to be more mobile, and often can be
moved a greater distance while maintaining its attachment to the superior pedicle.
◆ The superior pedicle reduction mammoplasty relies on the following arterial blood supply
(Fig. 20-1):
▲ Lateral branches of the intercostal arteries
▲ Lateral thoracic artery
▲ Perforating branches off the internal mammary artery
▲ Dermal plexuses of small arteries (mainly to the skin and NAC)
◆ In general, even a very large resection will not disrupt these arteries—hence the reliability of a
good outcome in most cases when using this technique.
Utility of Reduction
Mammoplasty Techniques
in Oncoplastic Surgery
Gail S. Lebovic
CHAPTER 20
332

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 333
Deep limit
of dissection
Lung
Lateral skin
flap
Lateral branch
of intercostal artery
Perforating
branches
of the internal
mammary artery
Lateral thoracic
artery
Medial
skin flap
Superficial limit of dissection
Thoracodorsal
vessels
Long thoracic nerve
Thoracodorsal nerve
is medial to vessels
Scapular
lymph nodes
Pectoralis
minor muscle
Latissimus dorsi
muscle
Teres major
muscle
Serratus
anterior muscle
Pectoralis
major muscle
Scapula
Internal
thoracic
artery
Figure 20-1

334 Section IV • Mastectomy
◆ Sensation to the breast is complex and consists of innervations of the skin and the NAC. The
anterior cutaneous branches of the fi rst through seventh intercostal nerves primarily innervate
the skin overlying the medial aspect of the breast, whereas the lateral cutaneous branches of
the second to the seventh intercostal nerves innervate the lateral aspect. The NAC derives its
innervation from the anterior and lateral cutaneous branches of the fourth intercostal nerve,
with contributions by the cutaneous branches of the third and fi fth intercostal nerves.
◆ Before surgery it is of paramount importance to discuss potential changes in sensation to the
skin overlying the breast and in particular the NAC with the patient. Although the surgical
approach discussed here usually does not cause a loss of sensation to the nipple, changes may
occur and patients should be prepared for and reconciled to this possibility.
Step 2. Preoperative Considerations
1. Patient Selection
◆ Reduction mammoplasty can be very useful in breast conservation surgery in appropriate
patients. This technique is particularly helpful in patients with large or pendulous breasts, and
with lesions located in the central and lower hemisphere of the breast (Figs. 20-2, A and B).
Local tissue fl aps are used to reconstruct the breast shape and the NAC is reconstructed with
standard techniques. In selected cases the NAC can be preserved and relocated to its new posi-
tion. The contralateral breast can be reduced or lifted at the same surgery and, if necessary,
adjuvant therapy can be administered to the affected side after the healing period.
◆ Patient selection is critical, and a complete work-up including history and physical examination,
detailed clinical breast examination, and thorough bilateral breast imaging (bilateral mammo-
graphy, ultrasonography, and magnetic resonance imaging [MRI]) should be obtained before
surgery. Preoperative BRCA testing should also be done in high-risk patients because if the
result is positive, a different surgical approach may be considered.
◆ MRI is particularly useful in patients with newly diagnosed cancer to confi rm the size and loca-
tion of the tumor in the breast, and to determine any other evidence of disease (i.e., multifocal
or contralateral lesions). Suspect lesions should be sampled for biopsy using minimally invasive
techniques before defi nitive surgical resection.
◆ Three-dimensional MRI can be very helpful with preoperative planning.
◆ Marking the site of the tumor with the patient standing and lying down is important to deter-
mine whether the tumor bed will be excised with a generous margin within the boundaries of
the reduction mammoplasty.
◆ Although there are numerous methods by which reduction mammoplasty can be performed,
this chapter focuses on the superior pedicle or Wise pattern reduction mammoplasty. This
procedure is the most straightforward for the surgeon in practice to learn and perform
reliably.
◆ Additional medical problems and lifestyle issues such as smoking should be taken into account
before surgery. These issues may increase the risk of complications such as delayed wound
healing and infection.

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 335
A
B
Figure 20-2

336 Section IV • Mastectomy
2. Preoperative Surgical Markings
◆ For preoperative marking, use a permanent marking pen (e.g., Sharpie) and an accurate mea-
suring tape marked in centimeters.
◆ Begin with the patient facing you in the standing position. Sit in front of the patient.
◆ Mark the midline by drawing a vertical line from the suprasternal notch to the umbilicus
(Fig. 20-3, A).
◆ Next, mark the breast meridian. This is done by measuring from the midline to the mid-
clavicular point (usually 7 to 8 cm from the midline; Fig. 20-3, B).
◆ A vertical line is drawn from the mid-clavicular point down to the nipple (Fig. 20-4).
◆ Next, the new SAP is marked by placing a hand beneath the breast and resting the middle fi nger
in the inframammary fold. A point is projected forward onto the breast and marked with the
pen. This is the “new” SAP (Fig. 20-5).

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 337
A
B
A
B
Figure 20-3
Figure 20-4
Figure 20-5

338 Section IV • Mastectomy
◆ From this point, measure and mark 10 cm medially (Fig. 20-6, A) and laterally (Fig. 20-6, B)
from the new SAP.
◆ Mark the inframammary fold with the marking pen; this can be done at any point while marking
the patient (Fig. 20-7, A).
◆ Mark a vertical reference line below the breast 8 to 9 cm from the midline. This will correspond
to the breast meridian above and will be the point for approximating the breast once the resec-
tion is complete (Fig. 20-7, B).
◆ With the patient standing facing forward, grasp the breast fi rmly and pull the breast toward
the midline. Draw a vertical line to connect the new SAP to the points previously marked at
10 cm, which are lined up with the reference point for the breast meridian beneath the breast
(Fig. 20-8, A). Similarly, pull the breast laterally (Fig. 20-8, B) (do not pull as fi rmly when
marking the medial aspect of the breast because this will result in a fl attened shape of the
breast).

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 339
A
Medial
B
Lateral
A
B
A
B
Figure 20-6
Figure 20-7
Figure 20-8

340 Section IV • Mastectomy
◆ Connect the vertical line to the inframammary fold medially (Fig. 20-9, A) and laterally
(Fig. 20-9, B).
◆ Once the preoperative markings are complete, photographs are taken (Fig. 20-10) and the
patient may proceed to the operating room.
3. Surgical Preparation
◆ We recommend wide skin preparation with povidone-iodine scrub and paint, followed by wide
draping with sterile drapes. Caution the scrub nurse not to erase the skin markings.
◆ A Foley catheter is placed because most cases take 3 to 4 hours.
◆ We also use thigh-high TED antiembolism hose and compression devices during the case, and
administer 1 g of cefazolin intravenously before surgery (in patients with penicillin allergy, we
use ciprofl oxacin 400 mg intravenously).
◆ The markings are then reinforced using methylene blue dye or a surgical marking pen.
Step 3. Operative Steps
◆ Dissection begins by scoring the outline of the areola using a “cookie cutter” nipple sizer (most
common size is 4.2 cm). The NAC is placed on four-way stretch and the outline for the new
areola is then made. The scalpel is used to score the area.
◆ A no. 22 scalpel blade (on a no. 4 handle) is used and dissection is carried down through the
epidermis to the level of the deep dermis. Electrocautery is then used for the remainder of the
dissection. This helps to signifi cantly decrease the amount of blood loss during surgery.
◆ Next, the inframammary incision is made in the same fashion, and the dissection is carried
down to the pectoralis major fascia using electrocautery (Fig. 20-11). The electrocautery typi-
cally is set to 40 to 45 (blend and spray). We use the coagulation mode for dissection rather
than the cutting mode because this also helps decrease bleeding.
◆ The inferior segment of the breast is elevated off the pectoralis muscle fascia using electrocau-
tery. Next, the medial and lateral incisions are made in the skin and the breast tissue is dissected
free down to fascia. On completing this dissection, the inferior wedge of tissue will be free from
the remaining superior pedicle with the NAC still attached (Figs. 20-12, A and B).
◆ Local anesthesia (1% lidocaine mixed with 0.25% bupivacaine, 1 : 1 dilution) is injected into
the underlying muscle, and a 15-Fr round drain is placed through a stab wound incision at the
lateral lower edge of the breast and secured to the skin with a single suture.

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 341
B
A
B
Figure 20-9
Figure 20-10
Figure 20-11
A
Figure 20-12

342 Section IV • Mastectomy
◆ Temporary closure is performed using skin staples. It is best to begin at the lateral edge, using
fi rm medial pulling to approximate the skin edges. Skin staples are placed every 2 cm until
the edge of the lateral fl ap is reached. Then the medial segment is secured, but when approx-
imating the medial segment, the breast tissue is not pulled as fi rmly as the lateral aspect.
This helps to preserve the conical shape of the breast, rather than giving it a fl attened appear-
ance (Fig. 20-13).
◆ If this technique is used for a central lumpectomy with a tumor adjacent to the NAC (partial
mastectomy), the NAC and central pedicle of the breast is excised down to the pectoral muscle
en bloc (Fig. 20-14). Next, the lateral and medial segments of the remaining breast tissue are
brought together medially and laterally, and the deep tissues are approximated with a number
of interrupted 3-0 Vicryl sutures.
◆ In either situation, the vertical incision is then closed temporarily with skin staples and the
patient is placed in the sitting position to determine the position of the new SAP. In most
patients, the NAC can be repositioned without diffi culty. However, in some cases, the distance
to the new SAP is greater than 10 cm, which usually is the limiting factor in raising the NAC
on a pedicle. If this is the case, the NAC may need to be transposed as a free nipple graft, and
it is secured in the same manner as a full-thickness skin graft.
◆ Once the new position for the SAP is determined, the segment of excess skin surrounding
the NAC is de-epithelialized. The medial and lateral skin fl aps adjacent to the vertical incision
are undermined 4 to 5 mm to mobilize the NAC on the superior pedicle (Figs. 20-15 and
20-16). All bleeding is controlled and the wounds are irrigated and checked once again
(see Fig. 20-12).

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 343
Figure 20-15
Figure 20-13
Figure 20-14

344 Section IV • Mastectomy
◆ The inframammary and vertical incisions are then sutured closed in a complex layered fashion
beginning with 3-0 or 4-0 polydioxanone (PDS) or Vicryl. The fi rst layer is placed in the deep
dermis, and a buried knot is used. Next, a 3-0 Prolene is used to close the skin, and any fi ne
details of skin approximation can be performed with 5-0 nylon suture. The Prolene stitch is
left in place for 3 weeks during the healing process (Figs. 20-15 and 20-16).
1. Case Examples: Specifi c Application of Breast Reduction to Oncoplastic Surgery
Case 1
◆ In this patient (Fig. 20-17), an occult tumor located in the 6 o’clock position of the right breast
was entirely removed within the inferior breast segment during the course of a routine reduc-
tion mammoplasty. The patient subsequently underwent radiation therapy, with some skin
changes still evident.

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 345
Figure 20-16
A
B
Figure 20-17

346 Section IV • Mastectomy
Case 2
◆ In this patient (Fig. 20-18), a central tumor of the left breast encroaching on the NAC was
resected along with the NAC. The breast was then reconstructed using the local tissue fl aps of
the breast in the same manner as a breast reduction. She underwent postoperative radiation
therapy and a subsequent nipple reconstruction. Note shrinkage of left breast following
radiation.
Case 3
◆ This patient presented with ductal carcinoma in situ of the left breast and a family history of
breast cancer (Fig. 20-19). Work-up revealed isolated disease in the left breast, and BRCA testing
was negative. She had a skin-sparing mastectomy of the left breast with a two-stage breast
reconstruction using a tissue expander, which was subsequently changed to a subpectoral
saline-fi lled implant. She also had a right breast reduction and left NAC reconstruction.

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 347
A
B
C
A
B
Figure 20-18
Figure 20-19

348 Section IV • Mastectomy
Case 4
◆ This patient had a long history of symptomatic macromastia and was found to have an invasive
tumor in the inferior lateral aspect of the right breast (Fig. 20-20). She underwent right central
partial mastectomy with reconstruction using the techniques described in this chapter, along
with a left breast reduction. Ultrasound-guided wire localization and sentinel node biopsy were
also performed at the time of surgery.
Step 4. Postoperative Care
◆ On completion, the chest is carefully cleaned and sterile dressings consisting of large petrolatum
gauze (Xeroform; Covidien, North Haven, Conn) are placed directly over the incisions. Next,
a sterile cotton roll is used for a soft layer of cushioning and then a breast binder or elastic
bandage wrap is used for compression dressing. This should be fi rm but not tight. The skin
under the drains is padded with cotton.
◆ Patients are placed on prophylactic antibiotics and remain on oral antibiotics for at least 2 weeks
after surgery. The drains are removed when they are draining less than 20 mL over 24 hours.
A supportive compression dressing (e.g., a sports bra) is worn 24 hours a day for the next 4
to 6 weeks.
◆ Exercise is limited to walking only during the fi rst several weeks after surgery. These restrictions
can be lifted as the patient progresses.
◆ The patient is not allowed to shower until the drains are removed.
◆ Regular activity is generally resumed 4 to 6 weeks after surgery.

Chapter 20 • Utility of Reduction Mammoplasty Techniques in Oncoplastic Surgery 349
A
B
Figure 20-20

350 Section IV • Mastectomy
Step 5. Pearls and Pitfalls
◆ Thorough preoperative evaluation of each patient is critical, including MRI of both breasts.
◆ Before trying this procedure, it is recommended that surgeons learn the procedure by taking
a course in oncoplastic surgery, practice the procedure in the cadaver laboratory, and scrub
on a number of cases with an experienced surgeon in order to feel comfortable with the
technique.
◆ This technique can be combined with other essential procedures such as preoperative wire
localization, intraoperative ultrasonography, and sentinel lymph node biopsy.
◆ Sit the patient up several times during surgery to check symmetry (ensure the patient is secured
to the table, and the table is working before induction of anesthesia).
◆ Prophylactic antibiotics can be discontinued after 7 to 14 days if there is no sign of infection.
Bibliography
Association of Breast Surgery at BASO, BAPRAS: Oncoplastic breast surgery: A guide to good practice. Eur J Surg Oncol 2007;33(Suppl):
S1-S23.
Clough KB, Lewis JS, Couturaud B, et al: Oncoplastic techniques allow extensive resections for conserving therapy of breast carcinomas.
Ann Surg 2003;237:26-34.
Clough KB, Nos C, Salmon RJ, et al: Conservative treatment of breast cancers by mammoplasty: A new approach to lower quadrant tumors.
Plast Reconstr Surg 1995;96:363-370.
Lebovic GS, Laub DR, Berkowitz RL: Aesthetic approach to simple and modifi ed radical mastectomy. Contemp Surg 1994;44:15-19.
Lebovic GS, Silverstein M, Laub DR: Oncoplastic surgery and breast health care. Semin Breast Dis 2004;7:140-147.
Petit JY, Rietjens M, Garusi C, Perry C: Integration of plastic surgery in the course of breast-conserving surgery for cancer to improve
cosmetic results and radicality of tumour excision. Recent Results Cancer Res 1998;152:202-211.

Step 1. Surgical Anatomy
◆ The chest wall, including skin, subcutaneous tissue, musculature, ribs, and parietal pleura, with
potential extension into visceral pleura and lung parenchyma, can be removed for resection of
locally recurrent breast cancer. Figure 21-1 labels major anatomic structures of the chest wall
from an external view.
◆ Care should be taken to avoid injuring the intercostal neurovascular bundles at the superior
and inferior edges of the resection by extending margins to the superior aspect of resected
ribs.
◆ The internal mammary artery (IMA) should be preserved for reconstructive pedicle fl aps or as
infl ow for free fl aps if possible. The IMA is shown in Figure 21-2, along with major anatomic
features from an internal view.
Step 2. Preoperative Considerations
◆ Indications for operation include isolated chest wall recurrence (Fig. 21-3), curative intent, or
palliation for painful, nonhealing, ulcerated lesions.
◆ Absolute contraindications to resections with curative intent include systemic disease or multi-
focal recurrence.
◆ Relative contraindications include advanced age, short disease-free interval, poor pulmonary
function, and high operative risk.
◆ Preoperative imaging and staging are essential for evaluation of chest wall anatomy, tumor
invasion into the lung, metastatic disease, pleural effusion, and preoperative planning. Magnetic
resonance imaging, positron emission tomography, and computed tomography are standard
imaging modalities. Bronchial washings may be appropriate to rule out direct lung invasion if
the imaging results cause suspicion.
◆ Resection extending beyond four ribs will usually require rigid chest wall reconstruction with
a mesh and methyl methacrylate sandwich. Mesh alone may be suffi cient for smaller defects
with less risk of fl ail chest.
Chest Wall Resection
John Harrison Howard, Ching-Wei D. Tzeng,
R. Jobe Fix, and Kirby I. Bland
CHAPTER 21
352

Chapter 21 • Chest Wall Resection 353
Common carotid artery
Pectoralis
minor muscle
Clavicle
Pectoralis
major muscle
Axillary artery
and vein
Internal mammary
neurovascular bundle
Intercostal
neurovascular bundle
Vein
Artery
Nerve
1
2
3
4
5
Sternum
Deltoid muscle
External intercostal
muscle
Lattisimus
dorsi muscle
Serratus
anterior muscle
Rectus abdominis
muscle
Internal intercostal
muscle
Innermost intercostal
muscle
A
B
Internal jugular vein
Figure 21-1
Recurrence
Figure 21-3
Brachiocephalic
vein
Subclavian artery
and vein
Internal mammary
neurovascular
bundle
Intercostal
neurovascular
bundle
Subclavian artery
and vein
Clavicle
Intercostal
muscle
Common carotid artery
Transversus
thoracis
muscle
Figure 21-2

354 Section V • Extensive Resections
◆ Recurrence location as well as the patient’s operative history will affect fl ap choice for defect
coverage. A latissimus pedicle fl ap is the most versatile and is usually the most readily available.
Flaps from previously radiated fi elds should be avoided if possible.
◆ Preoperative planning between oncologic and reconstructive surgeons should help elucidate
fl aps that will be available after oncologic resection.
Step 3. Operative Steps
1. Incision
◆ The patient should be intubated with a double-lumen endotracheal tube. Positioning may be
either supine or lateral decubitus, depending on location of recurrence and fl ap choice. Areas
of potential fl aps and skin graft donor sites should also be prepared and draped.
◆ Margins of 2 cm should be drawn around the planned area of resection. Margins should extend
one intercostal space above and below the mass to the superior aspects of ribs. Circumferential
full-thickness skin punch biopsies should be sent for frozen-section analysis to verify negative
margins before incision (Fig. 21-4).
◆ Once preoperative negative margins are verifi ed, extend the incision through the skin and the
pectoralis muscles to the chest wall using electrocautery (Fig. 21-5).
2. Dissection
◆ Before entering the pleural space, the ipsilateral lung should be defl ated. The thoracotomy
should be initiated through the superior margin of the planned resection (Fig. 21-6).

Chapter 21 • Chest Wall Resection 355
Punch biopsy
Figure 21-4
Pectoralis muscle cut
with electrocautery
Isolated chest wall
recurrence
Rib exposed
Completed
punch biopsies
Intercostal
muscle (cut)
Pectoralis
muscle (cut)
Rib
Incised
margin
Intercostal
muscle
Figure 21-5
Figure 21-6

356 Section V • Extensive Resections
◆ On entering the thorax, pleural adhesions caused by previous radiation therapy or surgery
should be bluntly dissected. If blunt dissection is inadequate, adhesiolysis should be performed
with sharp dissection to avoid the formation of a bronchopulmonary fi stula (Fig. 21-7). If the
parietal pleura is grossly adherent to the interior surface of the chest, a complete pleurectomy
may be necessary. Repair any pneumonotomies by oversewing with 3-0 nonabsorbable poly-
propylene sutures.
◆ After lysis of adhesions, the incision should be extended around the margin edges through the
intercostal muscles. Double-ligate intercostal neurovascular bundles with 2-0 silk stick ligatures
(Fig. 21-8).