Các Vấn Đề Trong Phẫu Thuật Tuyến Vú: Cẩm Nang Sửa Chữa (Repair Manual)

Part IV: Problems in Reduction Mammaplasty
522
TEACHING PO INTS
High pro le implants can enhance projection, especially i the majority o the de -
cit is in the central breast mound. Nipple position in patients with overresected
breasts can be improved as a result o two actors: (1) the implant creates ullness
in the superior portion o the breast, and (2) excising in erior pole skin shortens the
areola-to-IMF distance.
BIBLIO GRAPHY
Amini P, Stasch T, Theodorou P, et al. Vertical reduction mammaplasty combined with a superomedial
pedicle in gigantomastia. Ann Plast Surg 64:279-285, 2010.
Echo A, Guerra G, Yuksel E. The dermal suspension sling: shaping the in erior pedicle during breast
reduction. Aesthetic Plast Surg 35:608-616, 2011.
Eisenberg T. Simultaneous augmentation mastopexy: a technique or maximum en bloc skin resection
using the inverted-T pattern regardless o implant size, asymmetry, or ptosis. Aesthetic Plast Surg
36:349-354, 2012.
Michelle le Roux C, Kiil BJ, Pan WR, Rozen WM, Ashton MW. Preserving the neurovascular supply
in the Hall-Findlay superomedial pedicle breast reduction: an anatomical study. J Plast Reconstr
Aesthet Surg 63:655-662, 2010.
Neaman KC, Armstrong SD, Mendonca SJ. Vertical reduction mammaplasty utilizing the superome-
dial pedicle: is it really or everyone? Aesthet Surg J 32:718-725, 2012.
Swanson E. Prospective outcome study o 106 cases o vertical mastopexy, augmentation/mastopexy,
and breast reduction. J Plast Reconstr Aesthet Surg 66:937-949, 2013.

32c Overresection o Breast Tissue
El iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
Patient A, a 19-year-old woman, underwent an inverted-T in erior pedicle breast
reduction. She had 260 cc removed rom the right breast and 290 cc removed
rom the le t breast. She was 5 eet 1 inch tall and weighed 120 pounds. At 4 years
postoperatively she shows a good result, but 20 years later she was seen a ter a
15-pound weight loss. This patient’s breasts now appear overresected relative to her
current body weight. She did not request correction.
523

Part IV: Problems in Reduction Mammaplasty
524
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient initially had a good result. When she lost weight, the breasts became
smaller, especially in the upper pole o the breast. She has retained essentially the
same shape, but with loss o projection and upper pole ullness.
ANALYSIS O F THE PRO BLEM
Overresection is a relative problem. When a patient loses weight, the loss occurs
mainly in the upper pole o the breast.
RECOMMENDED SOLUTION TO THE PROBLEM
When a patient presents with a relative overresection, the standard correction
has been to insert a breast implant.
Fat injections could be considered.
TECHNIQ UE
The ollowing two patients show how di cult it can be to correct the problem.
Patient B presented or a breast reduction at age 36. She was 5 eet 3 inches tall and
weighed 170 pounds. She had a medial pedicle vertical breast reduction, with re-
moval o 300 cc rom the right breast and 325 cc rom the le t breast; 450 cc o at
was removed rom the lateral breast and chest wall areas.

Chapter 32 • Overresection of Breast Tissue

525
Her initial result at 1 year postoperatively shows a good result.
She then lost 50 pounds, with loss o volume mainly in the upper poles o her
breasts.
The patient underwent bilateral breast augmentation with textured silicone gel
breast implants. Both implants were 354 cc each. The result was good, but with
some descent o the implant into the lower pole o the breast.

Part IV: Problems in Reduction Mammaplasty
526
Un ortunately, as seen with patient B, her nipples were placed too high, and the
placement o an implant can exaggerate the problem.
This 28-year-old woman underwent an in erior pedicle inverted-T breast reduction
4 years be ore her consultation. She had lost 40 pounds in the interim. Both nipples
had been placed too high, and the weight loss resulted in volume loss mainly in the
upper pole. The in ramammary scar had risen on the breast with what appeared to
be descent o the IMF.
She underwent a bilateral breast augmentation with textured subglandular silicone
gel breast implants o 290 cc each. Un ortunately, the implants settled down into
the lower poles o her breasts, and although the implants corrected the volume de -
ciency, they did not stay in the high pocket that was created or them, and the de-
scent exaggerated the high nipple position.
It is important to try to keep the implant in a high pocket to prevent the inevitable
descent o the implant into the lower pole o the breast. A subpectoral pocket might
be a better choice than a subglandular pocket, but the ability o the muscle to hold
the implant up is overrated. This can be a particularly di cult problem when the
nipples were placed too high.

Chapter 32 • Overresection of Breast Tissue

527
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Adding an implant can help ll the volume o the breast, but it does not always
ll the upper pole as expected. I the implant descends into the lower pole o the
breast, the de ormity can be made somewhat worse.
TEACHING PO INTS
It is best to tailor the initial breast reduction to be proportional to the patient’s
body weight. Using an implant to correct the de ciency can help, but it also has
limitations. Fat injections may be better or lling the upper pole.
Patient A (no implant)
Patient B
Patient C

Part IV: Problems in Reduction Mammaplasty
528
BIBLIO GRAPHY
Courtiss EH, Goldwyn RM. Reduction mammaplasty by the in erior pedicle technique. An alternative
to ree nipple and areola gra ting or severe macromastia or extreme ptosis. Plast Reconstr Surg
59:500-507, 1977.
Georgiade NG, Sera n D, Morris R, Georgiade G. Reduction mammaplasty utilizing an in erior pedi-
cle nipple-areolar f ap. Ann Plast Surg 3:211-218, 1979.
Robbins TH. A reduction mammaplasty with the areola-nipple based on an in erior pedicle. Plast Re-
constr Surg 59:64-67, 1977.

C h a p t e r 33
UNDERRESECTION OF BREAST
TISSUE
33a Secondary Vertical Reduction Mammaplasty
el iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 34-year-old woman wanted improvement in her breasts a ter a breast reduc-
tion 10 years previously. She had residual areolar pigmentation on either side o
the vertical scar and desired urther reduction and improvement o ptosis. She was
5 eet 7 inches tall, weighed 190 pounds, and wore a size 36DD bra. Her previous
breast reduction was per ormed using an inverted-T in erior pedicle approach.
529

Part IV: Problems in Reduction Mammaplasty
530
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is somewhat low breasted with a low breast ootprint and a relatively
long distance rom her clavicles to her superior breast border. Her upper breast
border will remain unchanged with any orm o secondary reduction unless an im-
plant is added or at injections are per ormed. Areolar pigmentation is present on
both sides o the vertical scars. Her IMFs are well below her in ramammary scars
(dotted line). Her breast mound and nipple position are good. To make her breasts
smaller, her in erior poles need to be reduced and her nipples elevated slightly. I the
nipples are moved, they should be maintained on the previously created pedicle or
moved only slightly to sa ely maintain a random-pattern blood supply. Axial blood
vessels to other potential pedicles were likely destroyed during the previous cre-
ation o an in erior pedicle.
ANALYSIS O F THE PRO BLEM
This patient has excessive in erior pole parenchyma. With removal o some o the
glandular ptosis, her nipples will need to be moved slightly to be properly reposi-
tioned on the new, smaller breast mounds. The ideal nipple position is a third to
hal the distance up the breast mound.
RECOMMENDED SOLUTION TO THE PROBLEM
An in erior wedge resection o the in erior pole
Removal o pigmented areolar skin surrounding the vertical scars
Deepithelialization around the areolae
Elevation o the IMFs by liposuction

Chapter 33 • Underresection of Breast Tissue

531
TECHNIQ UE
The patient is shown on the operating table be ore and a ter secondary reduction.
A vertical approach was used with an in erior wedge resection o the in erior pole,
thereby removing the previous in erior pedicle. The pigmented areolar skin on ei-
ther side o the vertical scars was removed and the base diameter o the breasts
narrowed. No new pedicle was created or the NACs, but some skin around the
areolae was deepithelialized to elevate them slightly. They survived easily on a
r andom-pattern blood supply.
The in erior pedicle was removed with the in erior wedge resection. The IMFs were
elevated by liposuction between the olds and the scars. The IMFs were probably
lowered rom the weight o the tissue on them a ter the in erior pedicle approach.
The olds can be elevated to the level o the scar by resection o in erior paren-
chyma and removal o additional tissue above the old with liposuction.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 10 days and 7 weeks postoperatively.

Part IV: Problems in Reduction Mammaplasty
532
The patient is shown preoperatively and 2 years postoperatively.
Two years postoperatively, her improved breast projection and shape are main-
tained. Her upper breast border is unchanged, but her lower border (IMF) has been
elevated into the scar. Her bra there ore does not need to sit as low on her chest
wall as it did preoperatively.
TEACHING PO INTS
A secondary reduction does not necessarily require revision o the in ramammary
scar. The key step is to per orm an in erior wedge resection o the redundant lower
pole parenchyma through a vertical incision. Liposuction can help to raise low
IMFs to the level o the scars. This is per ormed between the olds and the scars.
The NACs can be elevated by deepithelialization and preservation o a random-
pattern blood supply. The creation o a new pedicle is not required.
BIBLIO GRAPHY
Ahmad J, McIsaac SM, Lista F. Does knowledge o the initial technique a ect outcomes a ter repeated
breast reduction? Plast Reconstr Surg 129:11-18, 2012.
Hall-Findlay EJ. Rereduction. In Hall-Findlay, EJ. Aesthetic Breast Surgery: Concepts & Techniques.
St Louis: Quality Medical Publishing, 2010.
Hudson DA, Skoll PJ. Repeat reduction mammaplasty. Plast Reconstr Surg 104:401-408, 1999.
Losee JE, Caldwell EH, Serletti JM. Secondary reduction mammaplasty: is using a di erent pedicle
sa e? Plast Reconstr Surg 106:1004-1008, 2000.
Matarasso A, Klatsky SA, Maxwell GP, et al. Secondary breast reduction [panel discussion]. Aesthet
Surg J 26:447-455, 2006.
Pandeya NK. In erior pedicle technique or reduction mammaplasty a ter a Strombeck reduction [let-
ter]. Plast Reconstr Surg 97:1306, 1996.
Rohrich RJ, Thornton JF, Sorokin ES. Recurrent mammary hyperplasia: current concepts. Plast Re-
constr Surg 111:387-393, 2003.
Würinger E. Secondary reduction mammaplasty [letter]. Plast Reconstr Surg 109:812-814, 2002.

33b Liposuction With Circumvertical Mastopexy
Den n is C. h a mmo n d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 16-year-old girl presented with uncomplicated symptomatic macromastia.
She had breast reduction using the short-scar periareolar in erior pedicle reduc-
tion (SPAIR) technique. A total o 473 g o tissue was removed rom her right
breast and 309 g rom the le t. Her postoperative recovery was uncomplicated, and
she had relie rom problems with her upper torso (neck and shoulder pain). She
is shown 1 year postoperatively with a signif cant reduction in the volume o her
breasts and an aesthetic breast shape.
Five years later, the patient presented with recurrent macromastia. She requested
breast reduction to relieve symptoms related to the weight o her breasts.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient had no children during the 5 years a ter her original breast reduction.
However, she has gained 10 pounds over her original preoperative weight.
533

Part IV: Problems in Reduction Mammaplasty
534
She has developed recurrent breast enlargement that is out o proportion to the rest
o her body habitus. This excess weight is causing recurrence o pain in her neck
and shoulders.
ANALYSIS O F THE PRO BLEM
Although the overall volume and weight o the patient’s breasts increased over the
past 5 years, the position o her NACs was ideal, as the most projecting aspects o
her breast mounds. Her breasts had enlarged symmetrically in all directions, creat-
ing a reasonable breast shape but with an excess o volume. In addition, her skin
envelope had expanded to accommodate her enlarged breasts. Her scars were well
healed and symmetry was reasonable, although the le t NAC was slightly lower
than the right.
RECOMMENDED SOLUTION TO THE PROBLEM
Suction-assisted lipectomy
A skin-only circumvertical mastopexy o the redundant skin envelope
Liposuction peripherally as needed
Tailor-stapling o the circumvertical pattern and tightening o the vertical limb
as needed
Insetting o the NACs
TECHNIQ UE
The procedure was per ormed with the patient under general anesthesia. The di-
mensions o the proposed circumvertical skin retailoring were marked, with care
taken not to overelevate the NACs. Tumescent technique and standard suction-
assisted lipectomy were used to remove the at rom each breast until the desired

Chapter 33 • Underresection of Breast Tissue

535
reduction in volume was obtained. Liposuction was per ormed peripherally as
needed, rom deep to superf cial. The area within the previously constructed in e-
rior pedicles was avoided to prevent inadvertent injury to the vascular supply to the
NACs. A total o 675 cc o at was removed rom her right breast and 750 cc rom
her le t breast. A ter the breast was debulked, the circumvertical pattern was tailor-
stapled into position, with tightening o the vertical limb as needed to shape the
lower pole and narrow the base diameter. Care ul skin tailoring o the circumvertical
pattern provided a symmetrical contour to the reduced breasts. Insetting the NAC
provided the f nal contour. The discrepancy between the areolar and periareolar in-
cision dimensions was managed using an interlocking Gore-Tex suture technique.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
One year postoperatively, the patient has an aesthetic breast contour with a stable
reduction in volume. An early exposure o the Gore-Tex suture on the right neces-
sitated removal 6 weeks postoperatively. This caused mild spreading o the NAC
diameter. The patient has declined revision to correct this asymmetry. Her upper
torso strain is relieved, and she is symptom ree.

Part IV: Problems in Reduction Mammaplasty
536
TEACHING PO INTS
Reduction o a breast whose nipple is already at the most projecting part o the
breast mound requires limiting o the skin resection above the existing superior
areolar border. The addition o a vertical segment to the circumvertical pattern will
have a li ting e ect on the breast. I the superior translocation o the NAC is too
aggressive, the f nal position o the NAC will be too high. For this reason, the su-
perior border o the areola is set 6 cm above the existing IMF, and the bulk o the
volume resection and skin excision is taken rom the lower portion o the breast. In
addition, during removal o the atty component o the breast, it is best to avoid the
area o the pedicle to maximally preserve the blood supply to the NAC.
When using the circumvertical skin pattern, superf cial deepithelialization ollowed
by wound closure without incision through the dermis will tighten a redundant
skin envelope without risk o embarrassment o the blood supply to the NAC or
breast parenchyma. A combination o these maneuvers allows sa e rereduction o
the breast in a consistent and predictable ashion.
BIBLIO GRAPHY
Hammond DC. Short scar periareolar in erior pedicle reduction (SPAIR) mammaplasty. Plast Recon-
str Surg 103:890-901, 1999.
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o areolar diam-
eter and shape. Plast Reconstr Surg 119:804-809, 2007.
Hudson DA, Skoll PJ. Repeat reduction mammaplasty. Plast Reconstr Surg 104:401-408, 1999.
Lejour M. Vertical mammaplasty as secondary surgery a ter other techniques. Aesthetic Plast Surg
21:403-407, 1997.
Rohrich RJ, Thornton JF, Sorokin ES. Recurrent mammary hyperplasia: current concepts. Plast Re-
constr Surg 111:387-393, 2003.

C h a p t e r 34
NIPPLE MALPOSITION
34a Correction With Subpectoral Breast Implants
el iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 33-year-old woman had a breast reduction using an inverted-T technique,
probably with an in erior pedicle. She developed some bottoming out and had the
breast reduction revised through the in ramammary incision, with removal o skin
and breast tissue. Many surgeons use this approach in an attempt to raise the IMF,
but it only results in a urther reduction o parenchymal volume. Removal o skin
alone will not raise the old. Suturing the old to the ribs is only occasionally suc-
cess ul. She had very little breast tissue and requested a correction.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s nipples are too close to her upper breast border as a result o the
original reduction. The revision attempted to reduce the lower pole and elevate
the IMF. However, unless the old is sutured to the ribs, a horizontal skin excision
alone will not correct the problem.
537

Part IV: Problems In Reduction Mammaplasty
538
ANALYSIS O F THE PRO BLEM
It is very di cult to change the ootprint and mound when the nipples are too high,
as in this patient. The ideal solution was to change the breast ootprint and raise
the upper breast border. The only way to do this was to add an implant. (Today, at
injections are a possible option.) The addition o an implant can lead to bottoming
out, especially when the IMF no longer has chest wall attachments. (This patient’s
olds were completely ree rom any adherence to the chest wall.) Reattachment
o ten is not success ul. Patients need to be in ormed o this possibility so that their
expectations are realistic. Breasts should not be positioned superior to the anterior
axillary crease. For this reason, and to decrease the chance o bottoming out, the
implants needed to be relatively small.
RECOMMENDED SOLUTION TO THE PROBLEM
Insertion o small implants or at injections to elevate the upper breast border
Excision o the scars and deepithelialization o the lower skin f aps
Reattachment o the IMFs to the chest wall at a higher level
TECHNIQ UE
A 225 cc saline implant was inserted into a subpectoral pocket. The muscle was not
detached. The ascia was closed in an attempt to help prevent the implant rom de-
scending. (In my experience, this is rarely success ul.)
Fifth rib
IMF
New IMF
location at
the fifth rib

Chapter 34 • Nipple Malposition

539
The scar was excised. The lower skin f ap was deepithelialized to provide tissue to
which the upper f ap could be sutured a ter the lower skin was elevated. The deepi-
thelialized skin was then raised and sutured to rib periosteum in an overcorrected
position.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 3 weeks postoperatively with her implants in place and her
IMFs raised above the desired level. The IMFs will inevitably move back down-
ward, especially with the added weight o the implants.
Sixteen months postoperatively, her IMFs had settled slightly. However, the im-
plants continued to e ectively elevate her upper breast borders. The e ect o rais-
ing both the upper and lower breast borders was to make the nipple appear to be
in a more centralized position. Elevation o the IMFs and the addition o implants
can ail, making the problem worse. In this case, both maneuvers were success ul
enough to correct the problem adequately.

Part IV: Problems In Reduction Mammaplasty
540
Time is not particularly orgiving. The patient is shown with some loss o improve-
ment 61⁄2 years postoperatively.
TEACHING PO INTS
It is very di cult to adjust the breast ootprint and/or mound to accommodate
nipples that were placed too high in a previous surgery. Only an implant (or at in-
jections) can be used to e ectively raise the upper breast border. Un ortunately, the
insertion o implants can be unsuccess ul i the IMFs are no longer adherent to the
chest wall. The IMF bers are normally skin- ascial attachments, and they need to
be reconstituted. It is challenging to achieve consistent results with old elevation.
It is essential to raise the in erior f ap and attach the deep tissues to the rib perios-
teum. A deepithelialized area on the lower f ap acilitates closure o the upper skin
f ap.
It is important to ollow patients over the long term to assess the e ectiveness o
various maneuvers. A ull year is needed to determine the early e ects o gravity. A
longer-term ollow-up usually shows some loss in improvement.

Chapter 34 • Nipple Malposition

541
BIBLIO GRAPHY
Babuccu O, Zeyrek T, Comert A, et al. In ragluteal sulcus: a histologic and anatomic reappraisal. Aes-
thetic Plast Surg 32:496-502, 2008.
Bayati S, Seckel BR. In ramammary crease ligament. Plast Reconstr Surg 95:501-508, 1995.
Boutros S, Kattash M, Wien eld A, et al. The internal anatomy o the in ramammary old. Plast Re-
constr Surg 102:1030-1033, 1998.
Carlson GW, Grossl N, Lewis MM, et al. Preservation o the in ramammary old: what are we leaving
behind? Plast Reconstr Surg 98:447-450, 1996.
Lockwood TE. Super cial ascial system o the trunk and extremities: a new concept. Plast Reconstr
Surg 87:1009-1018, 1991.
Muntan CD, Sundine MJ, Rink RD, et al. In ramammary old: a histologic reappraisal. Plast Reconstr
Surg 105:549-556, 2000.
Nanigan BR, Wong GB, Khatri VP. In ramammary crease: positional relationship to the pectoralis ma-
jor muscle origin. Aesthet Surg J 27:509-512, 2007.
Nava M, Quattrone P, Riggio E. Focus on the breast ascial system: a new approach or in ramam-
mary old reconstruction. Plast Reconstr Surg 102:1034-1045, 1998.
Pennisi VR. Making a de nite in ramammary old under a reconstructed breast. Plast Reconstr Surg
60:523-525, 1977.
Ryan JJ. Discussion: In ramammary old: a histologic reappraisal. Plast Reconstr Surg 105:557, 2000.
Ryan JJ. A lower thoracic advancement f ap in breast reconstruction a ter mastectomy. Plast Reconstr
Surg 70:153-158, 1982.

34b Correction With Breast Repositioning
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This patient had a breast reduction with what appeared to be a vertical technique
2 years previously. She complained o an abnormally high nipple location, with
her le t nipple signi cantly higher. She had a long vertical scar that extended rom
below her NACs in eriorly over the breast mound. Redundant tissue was present,
especially on the le t side, where the vertical incision ended. The patient was con-
cerned that she could not wear many o her clothes, because her nipples were in
such an abnormal, elevated position.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s NACs are signi cantly displaced superiorly. The distance rom the
bottom o the areola on the right side to the IMF is 15 cm, and on the le t this dis-
tance is 17 cm. Her breast mounds are o airly equal volume. The transverse scar
542

Chapter 34 • Nipple Malposition

543
on her right medial IMF may represent an attempt to modi y the redundant skin
at the bottom o the right vertical incision. Most o her breast tissue is in the lower
third o her breast mound.
ANALYSIS O F THE PRO BLEM
The attempted vertical pattern in the original surgery was done in such a manner
that an excessive distance was created between the areola and the IMF. It was not
possible to determine where the actual breast tissue resection was per ormed. The
question was whether improvement could be accomplished without removing the
NACs as composite gra ts and replanting them. The other issue was whether to re-
sect more breast tissue or attempt to reposition the remaining breast tissue into a
more appropriate position. It appeared that repositioning the in eriorly displaced
breast tissue superiorly might help correct the abnormal position o the NACs.
RECOMMENDED SOLUTION TO THE PROBLEM
Deepithelialize the skin transversely along the current IMF area
Full-thickness division o the in erior aspect o the deepithelialized dermis
Inversion o the deepithelialized segment with its attached breast tissue superi-
orly and deep to the breast
A ter recontouring the breast mound, determine whether to move the nipples as
composite ull-thickness skin gra ts
TECHNIQ UE
Initially the transverse ellipses o skin in the lower pole o the breasts were deepi-
thelialized. The distance rom the areola to the upper margin o the deepithelialized
skin was 8 to 9 cm.

Part IV: Problems In Reduction Mammaplasty
544
The lower portions o the deepithelialized ellipses were divided ull thickness, ol-
lowed by a subglandular dissection. Permanent sutures were then placed between
the deepithelialized area and the overlying breast tissue. This allowed inversion o
the lower third o the breast, creating superior ullness o the breast mound. At the
same time this allowed in erior rotation o the NACs. The abdominal skin along
the now-opened IMF was advanced superiorly and sutured to the ascia or stabi-
lization o the IMF. It then became apparent that the nipple position had improved
adequately to avoid repositioning them as ull-thickness skin gra ts. The skin was
closed transversely along the IMF.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Deepithelialization and superior rotation o the lower breast signi cantly corrected
the patient’s de ormity without moving the nipples as composite gra ts.
Deepithelialized
skin
Deepithelialized
skin
Subglandular dissection
NAC
rotated
Deepithelialized
skin sutured to
breast tissue
Abdominal skin
pulled superiorly
and sutured
to fascia to
create new IMF

Chapter 34 • Nipple Malposition

545
This maneuver created a signi cant improvement in the overall shape o the breast
as well as the nipple location. The original surgery had created an excessive verti-
cal scar elevating the NAC. It is apparent that some o the excessive elevation o the
NAC was in reality caused by bottoming out o the breast tissue and not just high
placement o the NAC.
TEACHING PO INTS
Bottoming out can occur in both breast reduction and breast augmentation surgery.
When bottoming out occurs a ter breast reduction, repositioning this tissue rather
than excising it can be bene cial. Correction o excessively high NACs may require
composite tissue trans ers, but in this case, this was avoided.
BIBLIO GRAPHY
Dickinson BP, Handel N. Approaching revisional surgery in augmentation and mastopexy/augmenta-
tion patients. Ann Plast Surg 68:12-16, 2012.
Spear SL, Albino FP, Al-Attar A. Classi cation and management o the postoperative, high-riding nip-
ple. Plast Reconstr Surg 131:1413-1421, 2013.
Spear SL, Albino FP, Al-Attar A. Repairing the high-riding nipple with reciprocal transposition f aps.
Plast Reconstr Surg 131:687-689, 2013.
Staley H, Serra MP. A technique to correct a malpositioned nipple within the con nes o a well-placed
areola. Ann Plast Surg 72:279-280, 2014.

(Trang không có chữ)

C h a p t e r 35
BOTTOMING OUT
35a Reduction of Excess Lower Pole Volume
el iz a bet h J. h a l l -Fin d l ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 49-year-old woman had bottoming out in eriorly a ter an inverted-T in erior
pedicle breast reduction 10 years previously. She wanted smaller breasts. She was
5 eet tall and weighed 140 pounds.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On assessment, the patient’s nipples appear to be too high but only because they
are in the upper third o her breast mounds. Her nipples are actually in a good
position in relation to the upper breast border (which does not change during a
re-reduction procedure). The problem is that she has too much volume in the lower
pole o her breasts.
ANALYSIS O F THE PRO BLEM
The patient’s main problem was recurrent hypertrophy in her lower poles. It was
not necessary to preserve the in erior pedicle, because the nipples did not need to be
moved. They could be preserved on a random-pattern blood supply, because a pedi-
cle was not necessary.
547

Part IV: Problems in Reduction Mammaplasty
548
Her in ramammary scars were several centimeters above her IMFs. It is unlikely
that the previous surgeon placed the scars above the IMFs, especially by 3 to 4 cm.
Either the scar became elevated on the mound, or the IMFs bottomed out. It is
my opinion that the inverted-T in erior pedicle techniques push down on the IMF,
causing it to bottom out. Pseudoptosis should be de ned as bottoming out o the
in ramammary old. This patient had both pseudoptosis and glandular ptosis, but
she did not have nipple ptosis. The treatment should be aimed at the rst two prob-
lems. Pseudoptosis is corrected by removal o weight and tissue above the IMF, and
glandular ptosis is corrected by removal o lower pole parenchyma.
Some surgeons would not be com ortable removing the in erior pole parenchyma,
because it contains the in erior pedicle. But i the nipples do not need to be moved,
then they can rely on a random-pattern blood supply i the pedicle is removed. A
new pedicle should not be created, because all o the axial vessels to other pedicles
were damaged during the original creation o an in erior pedicle.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the lower pole excess and liposuction above the IMF to allow it
to rise
TECHNIQ UE
The scars rom the previous inverted in erior pedicle breast reduction were much
higher than the IMFs. It was important not to take a wide ellipse. Alternatively, ex-
cess parenchyma rom under both the medial and lateral f aps was removed. The
tissue between the scars and the IMFs was suctioned to raise the IMFs to the level
o the scars.

Chapter 35 • Bottoming Out

549
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown preoperatively and 4 months postoperatively. The relation-
ship o the nipple to the breast mound is improved bilaterally. This was achieved by
changing the mound to t the existing nipple position. The nipples were not moved.
The upper breast border cannot be changed (except by implants or at injections),
but the lower pole can be reduced and the in ramammary old raised.

Part IV: Problems in Reduction Mammaplasty
550
The patient is shown more than 8 years postoperatively. She has gained 40 pounds,
which includes an increase in the size o her breasts.
TEACHING PO INTS
It is important not to create a new pedicle. This patient’s breasts were rereduced
by removal o the lower pole parenchyma. The nipples remained in their original
position.
BIBLIO GRAPHY
Ahmad J, McIsaac SM, Lista F. Does knowledge o the initial technique a ect outcomes a ter repeated
breast reduction? Plast Reconstr Surg 129:11-18, 2012.
Hall-Findlay EJ. Rereduction. In Hall-Findlay EJ, ed. Aesthetic Breast Surgery: Concepts & Tech-
niques. St Louis: Quality Medical Publishing, 2010.
Hudson DA, Skoll PJ. Repeat reduction mammaplasty. Plast Reconstr Surg 104:401-408, 1999.
Losee JE, Caldwell EH, Serletti JM. Secondary reduction mammaplasty: is using a di erent pedicle
sa e? Plast Reconstr Surg 106:1004-1008, 2000.
Matarasso A, Klatsky SA, Maxwell GP, et al. Secondary breast reduction [panel discussion]. Aesthet
Surg J 26:447-455, 2006.
Pandeya NK. In erior pedicle technique or reduction mammaplasty a ter a Strombeck reduction [let-
ter]. Plast Reconstr Surg 97:1306, 1996.
Rohrich RJ, Thornton JF, Sorokin ES. Recurrent mammary hyperplasia: current concepts. Plast Re-
constr Surg 111:387-393, 2003.
Würinger E. Secondary reduction mammaplasty [letter]. Plast Reconstr Surg 109:812-814, 2002.

36a Fat Transplantation
Da n iel A. Del Vec c h io
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 68-year-old woman had undergone a breast reduction in the distant past. She
was concerned about the poor shape o her breasts and described them as de ated,
with excessive hollowing or concavity in the upper poles. Although a larger and
uller breast shape was appealing, she did not want prosthetic breast implant sur-
gery. She had no history o breast cancer and no signif cant amily history o breast
cancer. She was a nonsmoker.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient demonstrates two problems related to reduction mammaplasty: inad-
equate upper pole ullness and overall breast de ation over time. These problems
are more likely to occur when breast reduction–mastopexy is per ormed in older
patients to treat breast de ation and ptosis rather than virginal breast hypertrophy.
With increasing scrutiny rom insurance payors, breast reduction surgery can result
in excessive breast tissue removal to quali y or reimbursement.
c h APt e r 36
UNSATISFACTORY SHAPE
OR CONTOUR
551

Part IV: Problems in Reduction Mammaplasty
552
Because the proportion o breast volume in the lower pole dominates overall breast
volume o hypertrophied or ptotic breasts, o ten an upper pole volume def ciency
or concavity results a ter reduction mammaplasty, especially in older patients. This
concavity is seen a ter many types o mammaplasty techniques, including superior
pedicle and in erior pedicle. It is apparently a mani estation o the breast de ormity,
rather than the specif c technique used to treat it. On lateral view, this patient has
an unaesthetic concavity in her upper pole and underprojection. Although her ster-
nal notch-to-nipple distance is ideal, indicating an excellent surgical outcome rom
her breast reduction, the overall aesthetics o her breasts are not ideal because o
volume def ciency and unaesthetic curvature and shape.
ANALYSIS O F THE PRO BLEM
In reduction mammaplasty o ten the goal is to reduce the breast mass to ameliorate
symptoms o back and shoulder pain and breast discom ort. In breast-li t surgery,
the goal is to treat ptosis, nipple-areolar malposition, and inherent shape problems.
The aesthetic metrics we have classically ollowed in reduction mammaplasty–mas-
topexy include nipple position with relation to the clavicles, IMF, and distance rom
the sternal notch. However, reduction o volume and placement o the nipples in
the proper two-dimensional position does not provide a per ectly aesthetic breast
in many cases. Concepts such as upper pole slope, proportion o volume in the up-
per pole versus lower pole, and convexity o lower pole curvature are vitally impor-
tant to overall breast aesthetics. Similar to late sequelae o ace-li t surgery, those o
reduction mammaplasty o ten are best treated with a combination o skin excision
and volume augmentation using autologous at. This technique provides breast re-
juvenation rather than individual e ects such as a li t or volume enhancement.
RECOMMENDED SOLUTION TO THE PROBLEM
Analysis o the patient’s preoperative breast volume
Fat transplantation using autologous at rom her thighs
TECHNIQ UE
Volumetric examination o the patient’s breasts was per ormed preoperatively
using three-dimensional imaging (Axis Three, Boston, MA). The breast volume was
230 cc on both sides.
From experience, we estimated that a doubling o breast volume would provide
adequate ullness to correct the contour and shape problems related to upper pole
concavity and inadequate breast projection. Fat injection in the lower pole was
considered, to raise the breast o the chest wall and increase projection. Approxi-
mately two thirds o the planned injection volume would be applied to the lower
pole, and the rest would be added to the upper pole to increase ullness and im-
prove the slope.

Chapter 36 • Unsatisfactory Shape or Contour

553
According to our initial studies in at transplantation to the breasts, approximately
60% o the injected volume is expected to remain a ter 1 year. There ore, to main-
tain a conservative, 50% volume increase, approximately 460 cc o at should be
transplanted or a resultant 230 cc volume increase.
Based on our ongoing work in recipient site physiology, the maximum amount o
transplanted at that can be placed success ully in any given system should not ex-
ceed a 1:1 ratio. Because this patient’s breast volume was 230 cc, only 230 cc could
be transplanted. The estimated 460 cc that was needed was excessive. There ore she
required preoperative expansion using the Brava external volume expansion device.
The patient underwent expansion or 2 weeks and achieved the volumetric goal o
460 cc.
The temperature in the operating room was set at 80° F (27° C) to minimize the
risk o hypothermia. A ter in usion o 4 L o tumescent solution into the patient’s
thighs, a total o 2500 cc o aspirate was removed using custom 4 mm diameter,
12-hole cannulas. This aspirate was allowed to decant at 1 times the orce o grav-
ity, and the excess crystalloid and blood was removed. Fat was trans erred into
60 cc syringes and spun using a hand-crank centri uge at 40 times the orce o grav-
ity or 2 minutes. This maneuver removed an additional 30% crystalloid rom the
at preparation. The additional crystalloid was then removed rom the syringes.
Fat was transplanted using a 14-gauge needle 1 cm caudal to the in ramammary
crease. A 14-gauge Coleman side-hole cannula was used, attached to one o the
60 cc syringes used to process at. With gentle thumb pressure and at a rate o 1 cc
per second, a reverse liposuction technique was employed to disperse and spread
the at in all areas o the breast. Transplantation moved rom deep to superf cial,
initially building the base o the “mountain o sand” in the prepectoral region and
then moving more superf cially on the breast mound at levels o approximately
1 cm at a time. By beginning in the prepectoral region and working distally or an-
teriorly along the breast mound, the width o the breast and breast projection were
increased, building on the layer immediately subjacent.
A total o 450 cc o at was injected into each breast. Initially a ter transplantation,
the patient’s original reduction mammaplasty scars were more visible, as a result o
the volume increase.

Part IV: Problems in Reduction Mammaplasty
554
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
One year postoperatively the patient has increased volume in both breasts and a
stable result. In addition to pure volume increase, her breast curvature, upper pole
concavity, and overall shape are improved. Breast projection is enhanced.
TEACHING PO INTS
Results in reduction mammaplasty are dynamic. They change over time as a patient
ages. Fat transplantation can be an e ective procedure to improve breast shape
a ter reduction mammaplasty, even in older patients. Thorough analysis o recipi-
ent site volume and capacity and sound surgical planning o the appropriate injec-
tion volume are vital or success ul results. When the capacity o the recipient site is
insu f cient to hold the volume o at that is desired to achieve the cosmetic (or re-
constructive) result, the recipient site must be expanded. Alternatively, the at trans-
plantation procedure should be staged, with smaller volumes o at transplanted
each time.

Chapter 36 • Unsatisfactory Shape or Contour

555
BIBLIO GRAPHY
Agutter P, Malone P, Wheatley D. Di usion theory in biology: a relic o mechanistic materialism. J
Hist Biol 33:71-111, 2000.
Blondeel PN, Hijjawi J, Depypere H, et al. Shaping the breast in aesthetic and reconstructive breast
surgery: an easy three-step principle. IV. Aesthetic breast surgery. Plast Reconstr Surg 124:372-
382, 2009.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e f cacy. Plast Reconstr Surg
119:775-785, 2007.
Del Vecchio D. Breast reconstruction or breast symmetry using recipient site preexpansion and autol-
ogous at gra ting. A case report. Ann Plast Surg 62:523-527, 2009.
Khouri R, Del Vecchio D. Breast reconstruction and augmentation using BRAVA external breast ex-
pansion and autologous at gra ting. In Spear SL, ed. Surgery o the Breast: Principles and Art,
3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2011.
Saxena V, Orgill D, Kohane I. A set o genes previously implicated in the hypoxia response might be
an important modulator in the rat ear tissue response to mechanical stretch. BMC Genomics
23:430, 2007.

(Trang không có chữ)

Problems in Breast
Reconstruction With
Prosthetic Devices
Pa r t V-A

Tissue expanders and breast implants have been an integral part o breast reconstruction or
many years. Although the designs and conf gurations or these devices may vary, there are a
number o potential problems that are consistently encountered.
Early in the evolution o tissue expander breast reconstruction, the initial philosophy was to
maximally stretch out the skin and so t tissue as much as possible in the f rst stage. The second
stage consisted o trying to create an acceptable result with a permanent implant, but creating
a reasonable contour and an IMF could be di f cult because the skin and so t tissue were over-
stretched. Over time, it became obvious that the key to success ul expander breast reconstruc-
tion was using the device at the f rst operation in a more conservative and reliable manner. This
led to the concept o base diameter, height, and projection with these devices that would allow
or the creation o a more natural breast. Thus the importance o shaping the breast appropri-
ately became the primary consideration to create a natural breast with the expander at stage
one, and avoiding the attempt to do everything at stage two. It became obvious with the more
advanced tissue expanders that creating a ref ned shape and contour as well as a reasonable IMF
improved the results with the permanent implant.
The problems encountered with expander/implant breast reconstruction are airly consistent.
Fortunately, with advances in technique and new devices, these problems are seen less re-
quently. For example, the problem o inadequate projection with expander/implant reconstruc-
tion can be minimized using techniques with ADM rein orcement. This allows better lower
pole expansion. With the adjunct o at injections, results with tissue expansion can o ten be
signif cantly enhanced. Problems with tissue expander–implant reconstruction can be either o
an acute or a delayed nature. Initial problems include malposition o the expander in which the
decision needs to be made whether to intervene early and reposition the device, as opposed to
continuing the expansion and making appropriate modif cations secondary at the time o per-
manent implant insertion. Other acute issues may be related to inadequate so t tissue coverage
or radiation injury that can lead to exposure or in ection. Delayed problems usually relate to
the f nal aesthetic result. Examples include inadequate projection, lack o an IMF, a old in the
wrong location, or NAC malposition. Severe contour problems may occur in the case o severe
capsular contracture. One problem unique to unilateral tissue expander reconstruction is recur-
rent ptosis in the contralateral breast, which may or may not have already had a mastopexy.
With expander/implant reconstruction, ptosis rarely develops over time; however, an unoper-
ated or ptotic contralateral breast can present with recurring problems.

Se c t io n o n e
Postoperative Complications
Chapter 37 Infection After Breast Reconstruction
37a Debridement and Drainage
37b Expander Replacement Combined With Autologous Tissue Trans er
Chapter 38 Capsular Contracture After Breast Reconstruction
38a Rigottomy and Fat Trans er (RAFT)
38b Capsulotomies With ADM A ter Radiotherapy
38c Explantation, Capsulectomy, and Reconstruction A ter Silicone Implant Rupture and Chronic
Hematoma
Chapter 39 Implant and Expander Malposition
39a Secondary Expansion With Implant Replacement
39b Secondary In ramammary Fold Correction During Expander Removal
39c Bilateral TRAM Flaps Combined With Expander-Implants
Chapter 40 Failed Expander/ Implant Reconstruction
40a Two-Stage Reconstruction Using Local Flaps
40b Reconstruction Using Local Tissue
40c Reconstruction With Tissue Expansion and Contralateral Reduction Mammaplasty
40d Reconstruction With Tissue Expander and Implant Replacement
40e Salvage With Latissimus Dorsi Flap and Expander
40 Revision Tissue Expander–Implant Reconstruction With Latissimus Dorsi Flap and Adjustable
Implant
40g Salvage o Failed Bilateral Expander Reconstruction With TRAM Flaps
40h Reconstruction With Free DIEP Flap
40i Salvage o Failed Bilateral Expander Reconstruction With Autologous Tissue Trans er
40j Implant Exposure A ter Nipple Reconstruction: Correction With Implant Replacement and
Latissimus Dorsi Flap
559

(Trang không có chữ)

561
c h APt e r 37
INFECTION AFTER BREAST
RECONSTRUCTION
37a Debridement and Drainage
Ma u r ic e Y. n a h a bed ia n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 50-year-old woman had recently diagnosed right breast cancer. A mass was
palpable. A core biopsy demonstrated in ltrating ductal cancer with a single posi-
tive lymph node. Imaging showed a 4 cm tumor. Her past medical history was unre-
markable. She did not use tobacco, was not diabetic, and took no medications. On
physical examination, her breasts were large and ptotic. She weighed 155 pounds
and had a body mass index o 25.4. She decided to proceed with a unilateral skin-
sparing mastectomy. Reconstructive options were reviewed and included two-stage
prosthetic reconstruction and autologous reconstruction. Her likelihood o having
chemotherapy and radiotherapy was almost certain. Given this scenario, my recom-
mendation was to consider two-stage prosthetic reconstruction using an acellular
dermal matrix (ADM).
The operation included a skin-sparing modi ed radical mastectomy and immediate
two-stage reconstruction using a 500 cc tissue expander and an ADM. The mastec-
tomy specimen weighed 700 g. The operation was unevent ul. Adequate bleeding
rom the distal skin edges was noted. The tissue expander was lled intraopera-
tively to a volume o 200 cc. The patient received intravenous antibiotics be ore
561

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
562
the incision was made and postoperatively or 24 hours. Oral antibiotics were pre-
scribed at discharge, and she was given instructions on drain care.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient probably has compromised per usion to her mastectomy skin f aps
that was not appreciated at the time o mastectomy. Fluorescent angiography was
not available at the time. As the tissues progressed to ull-thickness necrosis, the
milieu surrounding the tissue expander became less hospitable, and bacteria were
able to enter the periprosthetic space. Problems related to tissue per usion are more
common in women with mammary hypertrophy, nipple-sparing mastectomy, intra-
operative over ll o the device with increased pressure on the skin envelope, and in
women who use tobacco products.
ANALYSIS O F THE PRO BLEM
Tissue necrosis a ter mastectomy can be ull-thickness or partial-thickness. Partial-
thickness de ects usually will heal using local wound care measures and without
operative intervention. Full-thickness de ects usually require operative debridement
o all devitalized tissue. Retention o the device will depend on the internal appear-
ance o the periprosthetic space. With evidence o in ection, the device is usually re-
moved. I the periprosthetic space is clean but the device has been exposed, the area
is copiously irrigated, debrided, and usually a new device is inserted. I the ADM is
unincorporated, it usually is removed, because the likelihood o adherence in this
setting is low.
RECOMMENDED SOLUTION TO THE PROBLEM
Operative exploration
Debridement o necrotic tissue
Wound irrigation
Retention or removal o the device
Secondary closure as appropriate
On postoperative day 6, she presented to the o ce
with ischemic changes o the lower mastectomy skin.
It was di cult to determine whether the skin would
remain viable or not. Silvadene ointment was applied,
and the patient was instructed to apply this twice
daily. This ormed an eschar that slowly demarcated.
Plans were made to per orm an operative debride-
ment and secondary closure electively. In the interim,
the eschar separated and began to drain turbid f uid.

Chapter 37 • Infection After Breast Reconstruction

563
TECHNIQ UE
The necrotic tissue was delineated and measured 8 by 3 cm. This area was excised,
and a thin, membranous layer was noted underneath. On penetration, a turbid, se-
rosanguineous f uid collection was expulsed. Cultures were obtained, and it was de-
termined that this patient had Staphylococcus aureus. The ADM was not adhered
and was removed. The tissue expander was removed. A layer o granulation tissue
was present over the in erior mastectomy skin f ap and chest wall. This was de-
brided using a curette. The wound was copiously irrigated using a three-tiered ap-
proach. A 50% hydrogen peroxide solution was used, ollowed by a 50% povidone-
iodine solution and an antibiotic irrigation solution. The incision was closed in two
layers over a drain. The patient was placed on postoperative oral antibiotics or
1 week.
A ter a device is removed because o in ection, it is prudent to wait 6 months be ore
another device is placed. The other option is to reconstruct the a ected breast with
autologous tissue. This patient chose to have reconstruction with a deep in erior
epigastric per orator f ap. This procedure was per ormed without incident.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is very pleased with her outcome. She
has excellent breast contour. At a later date, asym-
metry will be corrected by a contralateral reduction
mammaplasty.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
564
TEACHING PO INTS
It is very important to adequately assess per usion to mastectomy skin f aps when
immediate breast reconstruction is planned. Although skin color and arterial and
venous bleeding rom the cut edges are usually reliable, partial-thickness or ull-
thickness necrosis can occur. This will sometimes result in in ection, which neces-
sitates removal o the device, and a ailed reconstruction. In high-risk patients, or i
skin per usion is questionable, technologies such as f uorescent angiography can be
use ul. This real-time evaluation will delineate the per used angiosomes and assist
with the initial debridement o mastectomy skin f aps.
When tissue necrosis is noted, it should be excised immediately at the time o de-
marcation. A ected tissue that is less than 4 cm can be debrided in an o ce set-
ting; however, areas larger than 4 cm are best removed in an operating room. I the
device is retained, it is usually exchanged and def ated to minimize pressure on the
skin f aps.
BIBLIO GRAPHY
Francis SH, Ruberg RL, Stevenson KB, et al. Independent risk actors or in ection in tissue expander
breast reconstruction. Plast Reconstr Surg 124:1790-1796, 2009.
Nahabedian MY, Tsangaris T, Momen B, et al. In ectious complications ollowing breast reconstruc-
tion with expanders and implants. Plast Reconstr Surg 112:467-476, 2003.
Nguyen MD, Chen C, Colakog˘lu S, et al. In ectious complications leading to explantation in implant-
based breast reconstruction with AlloDerm. Eplasty 10:e48, 2010.

37b Expander Replacement Combined
With Autologous Tissue Transfer
Al l en Ga br iel , G. PAt r ic K MAXWeLL
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 50-year-old woman presented with a mass in the upper middle portion o her
le t breast. An ultrasound examination identi ed a 12 by 12 by 10 mm irregularly
marginated hypoechoic mass at the 12 o’clock position 4 cm rom the nipple line.
No adjacent masses were identi ed. No suspicious le t axillary lymph nodes were
noted on radiographic evaluation. An open biopsy yielded Nottingham grade 2 in-
vasive ductal carcinoma in situ, solid type, moderately di erentiated. One hundred
percent o the tissue was estrogen receptor (ER) positive, progesterone receptor
(PR) negative, and human epidermal growth actor receptor 2 (HER2) negative.
Because the patient had a strong amily history (her mother had breast cancer in
her ties), she elected to have a bilateral mastectomy. She met both the oncologic
and reconstructive criteria or a nipple-sparing mastectomy.
The approach or the mastectomy was completed through bilateral IMF incisions.
Reconstruction involved the placement o 133 mV 400 cc expanders lled with
90 cc o f uid in a dual plane pocket with acellular dermal matrix (AlloDerm;
Li eCell, Branchburg, NJ). During the le t mastectomy, the lateral areolar biopsy
incision was used or ease o access. All incisions were closed with 3-0 Vicryl,
4-0 Vicryl, and 4-0 Monocryl.
565

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
566
The patient was seen on postoperative day 5 a ter her bilateral mastectomy with
immediate reconstruction. On postoperative day 14, she had areolar wound dehis-
cence and increasing erythema.
Given the early dehiscence o the incision, which became contaminated and subse-
quently in ected, the expander was exchanged and the lateral areolar wound was
closed with 4-0 PDS and 4-0 nylon horizontal mattress sutures. The exchange was
per ormed through the IMF incision with placement o a drain. No ADM was re-
moved. Cultures were negative. Expansions were started a ter the drain was re-
moved. The device was expanded to 360 cc by postoperative day 36.

Chapter 37 • Infection After Breast Reconstruction

567
The patient presented on postoperative day 42 with drainage rom her lateral areo-
lar incision and erythema.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient is a healthy nonsmoker and has a clinical in ection that needs to be
treated. Her pathologic status is avorable and she will not require adjuvant chemo-
therapy or radiotherapy.
ANALYSIS O F THE PRO BLEM
Immediate reconstruction a ter mastectomy has a higher complication rate than
delayed reconstruction, because healing o the mastectomy f aps and incisions is
unpredictable. Despite these statistics, many patients desire immediate reconstruc-
tion. We try to select the best candidates or these procedures. The success o these
procedures depends on many variables, including the mastectomy technique o the
breast surgeon, and thought ul selection o an incision and the appropriate patient.
In this case, i the lateral areolar incision had not been used at the central mound o
the so t tissue envelope, we may have completely prevented this complication. The
use o old incisions and repeated closing o the area cause continued tissue thinning
and provide the healing mastectomy f ap with an area o least resistance or break-
down. Should expansion be postponed or a ew months to allow the incisions to
continue to heal? The downside o waiting is that the so t tissue envelope changes
as it heals. We pre er to shape the breast be ore all o the skin changes occur.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the le t expander and placement o a drain with closure
Washout and replacement o the le t expander (def ated) and closure
Autologous reconstruction
Washout and replacement o the le t expander (def ated) and excision o the
NAC and closure
Washout and replacement o the le t expander and reconstruction o the de ect
with a latissimus dorsi f ap
Placement o implants bilaterally

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
568
TECHNIQ UE
A ter the loss o an expanded so t tissue envelope, repeating o the process a ew
months later has unique challenges. I possible, the immediately reconstructed
breast should be salvaged. In this case, salvage was already attempted. It bought
some time and did not completely solve the problem, because the lateral areolar in-
cision continued to be a nidus or complication. Given the highly inf amed nature
o the skin and ailure o our rst attempt, we knew that excision and closure might
not be success ul. The decision was made to salvage the le t breast again to pre-
serve the expanded so t tissue. However, the incision was riable; there ore autolo-
gous tissue was needed to support the healing phase o the lateral areolar incision.
A mini-latissimus f ap was used, and the expander was replaced.
The patient is shown 6 months a ter her le t breast salvage operation with a mini-
latissimus f ap and a 133 mV 400 cc expander, and 2 months a ter placement o
style 20 550 cc implants (Allergan, Irvine, CA) bilaterally.

Chapter 37 • Infection After Breast Reconstruction

569
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Twenty-six months a ter her original surgery, the patient has symmetrical recon-
structed breasts. It was necessary to salvage the le t breast or a more pleasing out-
come. I we had delayed her reconstruction, it would have been di cult to achieve
symmetry. This is particularly true in patients who have a nipple-sparing mastec-
tomy, which adds a completely new variable and complexity to the reconstruction
algorithm. Where should the nipple be positioned, and what level o lower pole
expansion should be achieved with respect to the nipple position? These questions
require care ul consideration to prevent overexpansion o the so t tissue envelope.
The patient is shown 10 days a ter
at injection and excision o a latis-
simus skin paddle.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
570
TEACHING PO INTS
This patient’s complication might have been prevented i the lateral areolar incision
had not been used at the original mastectomy. It is critical or the breast team (the
breast surgeon and plastic surgeon) to discuss preoperatively the best strategy to
avoid unnecessary incisions that can lead to postoperative complications.
The delicate nature o central mound incisions necessitates a care ul analysis to
determine whether autologous tissue is needed to salvage the breast mound. We
believe that the use o a mini-latissimus f ap to salvage a breast and preserve the
components produces a better long-term aesthetic outcome than removal o the
expander and repeating o the entire process. In our experience, these two options
result in di erent breast shapes.
BIBLIO GRAPHY
Alderman AK, Wilkins EG, Kim HM, et al. Complications in postmastectomy breast reconstruction:
two-year results o the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg
109:2265-2274, 2002.
Maxwell GP, Falcone PA. Eighty- our consecutive breast reconstructions using a textured silicone tis-
sue expander. Plast Reconstr Surg 89:1022-1034, 1992.
Miller AP, Falcone RE. Breast reconstruction: systemic actors inf uencing local complications. Ann
Plast Surg 27:115-120, 1991.
Nahabedian MY. AlloDerm per ormance in the setting o prosthetic breast surgery, in ection, and
irradiation. Plast Reconstr Surg 124:1743-1753, 2009.
Nahabedian MY, Tsangaris T, Momen B, et al. In ectious complications ollowing breast reconstruc-
tion with expanders and implants. Plast Reconstr Surg 112:467-476, 2003.