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

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
622
TECHNIQ UE
In the f rst stage o the procedure, the existing implant was removed and a tissue
expander placed. Preoperative cultures revealed only skin contaminants. On the
recommendation o an in ectious disease consultant, the patient was given intrave-
nous vancomycin. The open wound was elliptically excised, and all tissue o ques-
tionable viability was debrided. A textured 445 g silicone implant was removed; f -
brinous exudate was noted in the pocket, but no rank uid collection. A thorough
capsulectomy was per ormed to remove all potentially contaminated tissue and
prevent subsequent establishment o a biof lm. The pocket was then irrigated with
3 L o bacitracin antibiotic solution, using high-pressure pulse lavage. A Mentor
(Santa Barbara, CA) Siltex 600 cc medium height contour prof le tissue expander
was inserted and f lled to a volume o 200 cc. A drain was placed, and the surgical
incision was closed under minimal tension. The patient recovered unevent ully rom
this procedure.

Chapter 40 • Failed Expander/Implant Reconstruction

623
Gradual serial in ation o the expander was initiated at 5 weeks. The patient was
seen at intervals o 3 to 4 weeks, and approximately 150 cc o saline solution was
injected at each session. She requested that the tissue be stretched to match the vol-
ume o the contralateral side as closely as possible. The expander was slightly over-
f lled to a f nal volume o 700 cc.
The tissue expander was le t in place ully expanded or an additional 2 months. It
was then replaced with a 600 cc round smooth high prof le silicone implant.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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The patient then waited 3 more months be ore proceeding with the next and last
stage in her reconstruction. She is shown immediately be ore her f nal operation.
Because her right breast was slightly larger than her reconstructed le t breast, the
patient elected to undergo right reduction mammaplasty in conjunction with le t
NAC reconstruction. At that procedure, some excessive atty tissue o the axillary
tail on the right side and some subcutaneous tissue o the le t lateral thoracic wall
(a dog-ear rom the mastectomy incision) were removed with liposuction. A right
reduction mammaplasty was per ormed with a conventional Wise pattern skin in-
cision. A total o 200 g o tissue was resected in graduated ashion to achieve the
best possible symmetry. The right areola was deemed too small to be used as a do-
nor site or le t areolar reconstruction, so a ull-thickness skin gra t rom the right
upper inner thigh was used to reconstruct the le t areola. A composite nipple gra t
was harvested rom the patient’s right breast to reconstruct her le t nipple. Her
postoperative course was unremarkable.

Chapter 40 • Failed Expander/Implant Reconstruction

625
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 9 months a ter her f nal procedure. She underwent a series
o staged procedures designed to salvage her ailed implant reconstruction and
achieve symmetrical breasts. Her surgical course was relatively smooth, and the to-
tal elapsed time rom presentation to her f nal operation (NAC reconstruction with
a contralateral reduction mammaplasty) was only 10 months. She was grate ul that
her reconstruction was salvaged and was very satisf ed with the f nal result. Some
o the scars are becoming slightly hypertrophic, particularly on the lateral aspect o
her le t breast. The diameter o the areola is slightly larger on the right side, and the
le t nipple has lost some projection.
Minor touch-up procedures can be per ormed in the uture. The patient moved out
o state with her husband. However, she has remained in contact and continues to
do well 3 years a ter her reconstruction.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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TEACHING PO INTS
This case demonstrates one approach to salvage a breast reconstruction in which
implant exposure is imminent. It is likely that ap necrosis and wound separation
occurred as a result o an excessively tight secondary wound closure a ter debride-
ment o ischemic mastectomy aps and ap advancement to close the de ect. The
patient’s problems may have been exacerbated by the initial attempt to insert too
large o an implant (445 g) instead o a smaller prosthesis or a tissue expander.
By the time this patient presented with irreversible skin ap ischemia, wound sepa-
ration, and impending implant exposure, several therapeutic options were avail-
able. The conservative strategy (and one that can never be criticized) was to explant
the prosthesis, debride and close the wounds, and proceed with delayed reconstruc-
tion in the uture. The patient, however, was invested in her reconstruction and
willing to accept some risk o ailure in an e ort to salvage the prosthesis. Because
she had no systemic signs o in ection, and little i any evidence o cellulitis or in-
ection o the periprosthetic space, we thought that aggressive debridement and
insertion o a tissue expander had a good chance o success. In recent years there
has been a growing trend toward attempting salvage o contaminated, exposed and
even in ected prostheses, provided that adequate tissue debridement, insertion o
a brand new device, and tension- ree closure can be achieved. Other actors made
this case avorable or salvage: the patient did not smoke, did not receive prior ra-
diation, and was nonobese and relatively young.
Because o the patient’s history o delayed healing and wound separation, so t tis-
sue expansion was per ormed cautiously. The initial in ation was delayed approxi-
mately 5 to 6 weeks a ter placement o the expander. Once the device was ully
in ated, it was le t in situ or several months be ore being replaced by a permanent
prosthesis. Though the f nal result in this instance was satis actory, the surgery was
per ormed at a time when orm stable, shaped devices were not available in the
United States. Now that a wider array o implants is available, it should be possible
to optimize results even urther.
BIBLIO GRAPHY
Chun JK, Schulman MR. The in ected breast prosthesis a ter mastectomy reconstruction: success ul
salvage o nine implants in eight consecutive patients. Plast Reconstr Surg 120:581-589, 2007.
Gatti GL, Lazzeri D, Stabile M, et al. Salvage o an in ected and exposed breast device with implant
retention and delayed exchange. Plast Reconstr Surg 125:19e-20e, 2010.
Nahabedian M, Tsangaris T, Bahram M, et al. In ectious complications ollowing breast reconstruc-
tion with expanders and implants. Plast Reconstr Surg 112:467-476, 2002.
Prince MD, Suber JS, Aya-Ay ML, et al. Prosthesis salvage in breast reconstruction patients with peri-
prosthetic in ection and exposure. Plast Reconstr Surg 129:42-48, 2012.
Spear S, Howard M, Boehmier J, et al. The in ected or exposed breast implant: management and treat-
ment strategies. Plast Reconstr Surg 113:1634-1644, 2004.

40d Reconstruction With Tissue Expander
and Implant Replacement
Al l en Ga br iel , G. Pa t r ic k Ma x w el l
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 49-year-old woman was diagnosed with clinical stage II cancer o her le t
breast. She had two lumpectomies with positive margins, and a mastectomy was
recommended. She decided to have bilateral mastectomies. She had no amily his-
tory o breast cancer. Her BMI was 46.2, and she had no medical comorbidities.
The patient was a nonsmoker and had an active li estyle.
The approach or a skin-sparing mastectomy was per ormed through central
mound incisions. Reconstruction was per ormed with placement o 133 mV 500 cc
expanders in a dual plane pocket with acellular dermal matrix (ADM) (AlloDerm;
Li eCell, Branchburg, NJ). They were f lled with 120 cc o uid. Botox was injected
into her pectoralis muscle. All incisions were closed with 3-0 Vicryl, 4-0 Vicryl, and
4-0 Monocryl.
627

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
628
The patient is shown on postoperative day 9. On postoperative day 16, she had
worsening le t central mound ap necrosis. The necrosis subsequently led to dehis-
cence on postoperative day 20. She was otherwise healthy.
Postoperative day 9
Postoperative day 16
Postoperative day 20

Chapter 40 • Failed Expander/Implant Reconstruction

629
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Nearly 3 weeks postoperatively, the patient has a problem that sometimes occurs
a ter immediate reconstruction. She has multiple options at this point, because the
area is not in ected. However, one concern is potential contamination, because the
expander is almost exposed. Is the oreign, nonvascularized ADM material contam-
inated/colonized? A great deal has been discussed about the development o bio-
f lm. Surgeons need to understand the makeup o biof lm to help ensure long-term
success ul outcomes or these patients. At this point her pathology is avorable and
she will not require adjuvant chemotherapy or radiotherapy.
ANALYSIS O F THE PRO BLEM
Exposure o an implant or ADM early a ter reconstruction is problematic. These
patients need to be ollowed closely, because timely management can a ect the
long-term outcome. When is the appropriate time to debride the scab or necrotic
mastectomy ap? We have been taught to wait until the area demarcates itsel .
How long does demarcation take? Clinical judgment should be used to determine
the timing o debridement, which can be as early as 1 to 2 weeks. In ection o the
expander is not the only concern; colonization o the ADM and expander with
biof lm is possible. Surgeons need to understand the detrimental e ects o in am-
mation caused by planktonic and biof lm bacteria on wound healing. Because this
patient’s necrotic area was poorly vascularized, many strains o bacteria are most
likely present. However, they might not be metabolically active. Metabolic activity
is required or antibiotics to be e ective. In another possible scenario, one strain o
bacteria can be active and targeted by an antibiotic, and with time another strain
within the biof lm community becomes active and causes complications.
Is the ADM also a ected? ADM requires vascularization a ter implantation to be-
come incorporated. The area just beneath the mastectomy ap necrosis most likely
will not be vascularized, because it lacks contact with vascularized tissue. Excision
and removal o the ADM along with overlying tissue is necessary. The nonincor-
porated ADM will have to be removed; this can be the entire ADM or just the por-
tion o ADM that is not incorporated. Should the expander be removed? Given the
nature o biof lm and its reaction to oreign nonvascular materials, removal o the
expander is recommended. Biof lm bacteria have a high tolerance to antibiotics, an-
tiseptics, and disin ectants. Complete removal or mechanical debridement is needed
to break the protective layer o biof lm.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
630
RECOMMENDED SOLUTION TO THE PROBLEM
Debridement o the incision
De ation and removal o expander
Curettage o the pocket
Insertion o a new expander
Insertion o a drain and closure
Drain removal and expansion
Removal o expanders and delayed implant placement
TECHNIQ UE
The plan was thoroughly discussed with the patient. She was in ormed o the possi-
bility o having a de ated expander postoperatively. The procedure was per ormed
in the operating room under general anesthesia.
The horizontal incision was debrided. The expander was immediately exposed. As
expected, the ADM beneath the necrotic mastectomy ap was not incorporated.
The ADM just under the necrotic tissue was debrided; there was no sign o puru-
lent material present. The surrounding areas were debrided, and the expander was
de ated and removed. Thick f brinous exudate was noted at the central aspect. This
is consistent with impaired healing by stimulation o chronic in ammation, leading
to elevated levels o proteases that degrade proteins that are essential or healing.
The pocket was debrided with a curette, and a new expander was placed a ter ir-
rigation o the pocket with triple antibiotic solution. The rest o the ADM that was
in contact with healthy vascularized tissue was incorporated. Minimal volume was
placed in the expander, a drain was inserted, and the incision was closed.

Chapter 40 • Failed Expander/Implant Reconstruction

631
The patient is shown 4 days postoperatively. The drain was removed 12 days post-
operatively. The expander was ully f lled to 500 cc by postoperative day 42.
The patient then had bilateral breast reconstruction with Style 45 800 cc implants
(Allergan, Irvine, CA), with radial lower pole scoring o her le t side. She is shown
40 days postoperatively.
Postoperative day 4
Postoperative day 12
Postoperative day 42

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Sixteen months a ter the second stage o re-
construction, the patient has symmetrical
breasts. She had two sessions o at gra t-
ing as well as nipple reconstruction, and she
declined areolar tattooing. Her breasts have
bilateral Baker I capsular contracture. She
was in ormed that multiple stages will be re-
quired to achieve a desired outcome. She is
pleased with her result and the balance that
the procedure has restored to her body.

Chapter 40 • Failed Expander/Implant Reconstruction

633
TEACHING PO INTS
When planning an immediate reconstruction, all e orts are made to ensure that re-
construction is per ormed with healthy mastectomy aps. This can be challenging
at times when epinephrine is used during the mastectomy, because ap survival is
di f cult to determine. Once necrosis is recognized, adequate time or declaration is
needed to ensure only one trip to the operating room. What is the ideal time—1 to
2 weeks? In some cases, mastectomy skin necrosis overlies the pectoralis muscle
and it may not cause problems. However, once necrosis is over the ADM, more
aggressive management is needed. During this waiting period the wound has ad-
vanced and become colonized with both planktonic and biof lm bacteria. Biof lms
are communities o bacteria encased in a sel -produced matrix o polysaccharides,
protein, and DNA that provides high levels o tolerance to antibodies, antibiotics,
and antiseptics. The only option or eradication is adequate debridement o all lay-
ers involved. This includes necrotic skin and underlying tissue, and the matrix and
expander i the necrotic area is directly over ADM. Both the expander and ADM
are avascular, serving as great media or bacterial colonization and biof lm orma-
tion. These management principles can be compared with those o exposed hard-
ware. Similar principles can be used or expanders with overlying nonvascular
ADM and a necrotic mastectomy ap. It is arguable that with early management
(within 5 days), removal o the expander may not be necessary. Clinical judgment
and thorough evaluation o the pocket are necessary to make the decision.
Some surgeons consider a delayed reconstruction in patients with a high BMI, be-
cause complication rates are higher in this population. Generally, the complications
associated with higher-BMI patients include seromas. It is critical to ensure com-
plete closure o the pocket, because this minimizes seroma ormation, and to re-
create an optimal environment or incorporation and healing o the pocket.
The true base width o a patient’s chest needs to be measured. This patient had a
tremendous amount o subcutaneous tissue laterally. The lateral and medial pinch
test results need to be subtracted rom the measurement o the entire breast width.
I this is not done, the chosen expander may have a base width o 17 to 19 cm. An
expander with a base width greater than 15 cm is rarely required. Early conf rma-
tion o true breast dimensions plays an important role in the long-term outcome o
these patients.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
634
BIBLIO GRAPHY
Collis N, Sharpe DT. Breast reconstruction by tissue expansion: a retrospective technical review o
197 two-stage delayed reconstructions ollowing mastectomy or malignant breast disease in 189
patients. Br J Plast Surg 53:37-41, 2000.
Harcourt DM, Rumsey NJ, Ambler NR, et al. The psychological e ect o mastectomy with or with-
out breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg 111:1060-1068,
2003.
Malata CM, McIntosh SA, Purushotam AD. Immediate breast reconstruction a ter mastectomy or
cancer. Br J Surg 87:1455-1452, 2000.
Miller AP, Falcone RE. Breast reconstruction: systemic actors in 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 ir-
radiation. Plast Reconstr Surg 124:1743-1753, 2009.

40e Salvage With Latissimus Dorsi Flap and Expander
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 64-year-old woman previously had a right modif ed radical mastectomy with
immediate insertion o a tissue expander. She smoked two packs o cigarettes a day.
She reported that skin overlying the expander died and the expander was removed.
The patient presented 3 months a ter expander removal, with a healing transverse
mastectomy scar. She wished to discuss options or another attempt at reconstruc-
tion and specif cally desired a single operation. At the time o consultation, I ex-
plained to the patient that unless she stopped smoking I would not consider per-
orming her breast reconstruction. The patient agreed to stop smoking. I told her
that I would see her in 2 months to determine whether she was compliant and to
assess the healing o her wound.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a healing right transverse mastectomy scar and a le t, large ptotic
breast. The pectoralis muscle and so t tissue in the area has been severely damaged.
The patient’s ribs are palpable immediately under the skin aps.
ANALYSIS O F THE PRO BLEM
It is di f cult in this type o patient to reinsert a tissue expander in the original mas-
tectomy site. The pectoralis muscle and the surrounding so t tissues were damaged
and attempts to reexpand the skin were likely to ail. Although the patient stopped
smoking, urther expansion has a high complication rate because o ischemia o
the original mastectomy aps. Another actor in this patient’s management was
that she wanted to have only one more major operation. There ore autologous tis-
sue trans er was essentially the only viable solution. Two options or pedicle tissue
were a TRAM ap or a latissimus dorsi ap with an expander-implant. A ree tissue
trans er was an alternative.
635

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
636
RECOMMENDED SOLUTION TO THE PROBLEM
Latissimus dorsi myocutaneous ap with a permanent saline expander-implant
(Spectrum; Mentor, Santa Barbara, CA)
Le t augmentation-mastopexy
Delayed NAC reconstruction once the breasts are symmetrical
TECHNIQ UE
Once the patient’s right breast incision healed, she was taken to the operating room
or reconstruction. The original mastectomy scar was opened, and the superior
and in erior aps were elevated. The skin aps appeared viable, and tissue debride-
ment was not required. This portion o the procedure was done with the patient in
a lateral position so that the right latissimus dorsi myocutaneous ap could be har-
vested at the same time. The skin island was designed in the center o the latissimus
dorsi muscle obliquely so that when it was rotated anteriorly, adequate muscle was
available to place beneath the original in erior and superior mastectomy aps. This
provided complete coverage o the replacement expander by latissimus dorsi mus-
cle. The patient’s pectoralis muscle was no longer available, because it was dam-
aged in the original surgery. A 700 cc anatomic expander was inserted beneath the
latissimus dorsi muscle. The muscle was sutured to the chest wall and surrounding
tissues, completely closing o the pocket. The skin island, which measured approxi-
mately 14 by 6 cm, was sutured between the in erior and superior mastectomy
aps.

Chapter 40 • Failed Expander/Implant Reconstruction

637
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Postoperatively the patient did well, with no evidence o in ection or skin necrosis.
The overlying tissue was progressively expanded over the course o several months.
A ter the expanders were in ated to a volume o approximately 700 cc, a minor
surgical procedure was per ormed to create a right NAC using a skate ap. The pa-
tient had good symmetry o volume, NAC location, and IMF position. Projection
o her reconstructed breast equaled that o the augmentation-mastopexy side. Her
result is stable 2 years postoperatively.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
638
TEACHING PO INTS
Immediate tissue expander reconstruction in heavy smokers has a high probability
o ailure. Any attempt at reexpansion in this group o patients has a high probabil-
ity o ailure. Autologous tissue reconstruction, whether pedicle or ree, has the best
chance or success in this di f cult group. Expansion is easible, as presented in this
case, as long as new tissue such as a latissimus dorsi ap is part o the procedure.
BIBLIO GRAPHY
Cagli B, Manzo MJ, Tenna S, et al. Heterologous reconstruction and radiotherapy: the role o latissi-
mus dorsi ap as a salvage. Acta Chir Plast 54:45-51, 2012.
Gust MJ, Nguyen KT, Hirsch EM, et al. Use o the tabbed expander in latissimus dorsi breast recon-
struction. J Plast Surg Hand Surg 47:126-129, 2013.
Levine SM, Patel N, Disa JJ. Outcomes o delayed abdominal-based autologous reconstruction versus
latissimus dorsi ap plus implant reconstruction in previously irradiated patients. Ann Plast Surg
69:380-382, 2012.
Rabey NG, Lie KH, Kumiponjera D, et al. Salvage o ailed prosthetic breast reconstructions by autol-
ogous conversion with ree tissue trans ers. Eplasty 13:e32, 2013.
Tadiparthi S, Staley H, Collis N, et al. An analysis o the motivating and risk actors or conversion
rom implant-based to total autologous breast reconstruction. Plast Reconstr Surg 132:23-32,
2013.

40f Revision Tissue Expander–Implant Reconstruction
With Latissimus Dorsi Flap and Adjustable Implant
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 58-year-old woman had bilateral subcutaneous mastectomies 10 years previ-
ously, when implants were inserted. She had a Baker grade IV capsule on her right
side and impending implant extrusion beneath the NAC. Eventually the tissue over
the areola broke down, and the implant was removed. The plan was to allow the
wound to heal or approximately 3 months and then per orm reconstruction.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The so t tissues immediately beneath the patient’s NAC are very thin; this is the
area where the implant is eroding through. The patient’s right IMF is elevated, and
her skin envelope is contracted.
639

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
640
Although the NAC is viable, no so t tissue is present immediately beneath it. The
patient’s le t breast implant is so t and without problems.
ANALYSIS O F THE PRO BLEM
Capsular contracture not only can distort a breast mound, but it can cause signif -
cant thinning o the overlying tissues and erosion, as in this case. No protective
layers o tissue remain a ter a subcutaneous mastectomy. Capsular contracture can
lead to overlying tissue necrosis. The NAC was the weakest point in this patient’s
breast and became the site o erosion. Additionally, her entire skin envelope con-
tracted a ter the implant was removed. This patient had two major problems: loss
o skin sur ace area and loss o subcutaneous tissue centrally. Her IMF was ele-
vated, but this is relatively easy to correct.
RECOMMENDED SOLUTION TO THE PROBLEM
Autologous ree tissue trans er
Creation o a latissimus dorsi ap, designed specif cally or this patient’s central
tissue loss

Chapter 40 • Failed Expander/Implant Reconstruction

641
TECHNIQ UE
A latissimus dorsi f ap with the skin island eccentrically located on the muscle
was rotated anteriorly to improve the status o the IMF and provide so t tissue
in the central breast mound. The entire procedure was accomplished through an
in ramam mary incision to prevent trauma beneath the thinned NAC. An adjustable
saline implant was placed deep to the latissimus dorsi muscle, and the skin island
was sutured along the new IMF location. Postoperatively the saline expander-
implant was inf ated until symmetry was adequate.
Latissimus dorsi muscle
flap sutured to
pectoralis major above

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
642
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The inset latissimus dorsi skin island has allowed accurate reestablishment o the
patient’s right IMF with excellent symmetry. The tissue expander has re-created vol-
ume and improved the NAC position and breast shape. Lateral postoperative views
show excellent symmetry in volume and overall slope and projection o her breast
mounds.

Chapter 40 • Failed Expander/Implant Reconstruction

643
TEACHING PO INTS
Once a patient has impending erosion and decreased so t tissue, delayed recon-
struction is usually the best option. Sa e expansion requires adequate so t tissue; in
this case it was provided by the latissimus dorsi muscle. Loss o the IMF requently
requires replacement o skin.
BIBLIO GRAPHY
Cagli B, Manzo MJ, Tenna S, et al. Heterologous reconstruction and radiotherapy: the role o latissi-
mus dorsi ap as a salvage. Acta Chir Plast 54:45-51, 2012.
Gust MJ, Nguyen KT, Hirsch EM, et al. Use o the tabbed expander in latissimus dorsi breast recon-
struction. J Plast Surg Hand Surg 47:126-129, 2013.
Levine SM, Patel N, Disa JJ. Outcomes o delayed abdominal-based autologous reconstruction versus
latissimus dorsi ap plus implant reconstruction in previously irradiated patients. Ann Plast Surg
69:380-382, 2012.
Rabey NG, Lie KH, Kumiponjera D, et al. Salvage o ailed prosthetic breast reconstructions by autol-
ogous conversion with ree tissue trans ers. Eplasty 13:e32, 2013.
Tadiparthi S, Staley H, Collis N, et al. An analysis o the motivating and risk actors or conversion
rom implant-based to total autologous breast reconstruction. Plast Reconstr Surg 132:23-32,
2013.

40g Salvage of Failed Bilateral Expander Reconstruction
With TRAM Flaps
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This patient previously had bilateral mastectomies and immediate reconstruction
with submuscular tissue expanders. Postoperatively she developed bilateral in ec-
tions and skin ap necrosis. Both devices were removed. The patient presented
1 year a ter her original procedure, with signif cant scarring and tissue loss. The
mastectomy incisions were inverted-T patterns. She did not have radiotherapy but
had f nished chemotherapy. She requested bilateral reconstruction.
644

Chapter 40 • Failed Expander/Implant Reconstruction

645
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has signif cant scarring at the apex o the inverted-T incision, with con-
tracture o the aps. Her IMFs were no longer present. The horizontal component
o the mastectomy scar is high on the patient’s chest. The horizontal scars extend
rom the central sternum to under the arms. Her pectoralis muscles are retracted
superiorly. A visible groove at the lower portion o this muscle probably indicates
where it had been divided and elevated.
ANALYSIS O F THE PRO BLEM
This patient had extensive scarring on her anterior chest wall. Because tissue ex-
panders were inserted deep to the muscle at the time o the mastectomies, the thin,
overlying skin aps are adherent to the muscle. The remaining skin sur aces were
contracted and irregular. Attempts to re-expand this skin are unlikely to succeed.
Not only is the skin scarred, but the underlying muscle is probably scarred and
sti , and there ore resistant to urther expansion. New autologous tissue is re-
quired. Multiple options are available, including bilateral TRAM aps with no im-
plants and bilateral latissimus dorsi aps with a new set o expanders. With this pa-
tient’s history, the best choice was autologous tissue such as bilateral TRAM aps,
without any type o device.
A major issue in this patient was the absence o her in ramammary olds. TRAM
aps are an excellent choice. They can be used to create new olds and provide cov-
erage a ter excision o the scarred and contracted mastectomy aps. It was criti-
cal to design a airly large skin island rom the TRAM aps to totally resur ace the
area.
RECOMMENDED SOLUTION TO THE PROBLEM
Wide excision o the scarred mastectomy aps bilaterally
Identif cation o the new IMF locations
Bilateral TRAM aps with large skin islands

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
646
TECHNIQ UE
All o the contracted skin rom the mastectomy aps was excised. The resection
included both the transverse and vertical components o the original T incision.
Skin was removed as a airly large ellipse down to the underlying muscle. Bilateral
TRAM aps were raised in the standard manner. The aps were then inset ipsilat-
erally. The original medial portion o each ap was used to create a new IMF, and
the lateral portion was placed superiorly. Slightly more damaged skin was removed
rom the le t side than the right; there ore a slightly larger skin island was required
on the le t. The aps were inset be ore they were deepithelialized to ensure that
enough skin was available rom the aps to cover the de ects. Nipple-areolar recon-
struction was de erred to a later date.
Buried
epithelialized skin
TRAM flap
skin island
Contracted skin from
mastectomy flaps excised
Rectus incision
TRAM flap skin
island rotated
into lower pole

Chapter 40 • Failed Expander/Implant Reconstruction

647
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Two years later, the patient has an excellent, symmetrical result that is stable.
The problem with any large ap is that it creates a patchlike appearance on the
breast, which is unavoidable. I this patient’s abdominal tissue had been inadequate,
another solution would have been necessary. It is critical to select the appropriate
operation or each specif c problem.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
648
TEACHING PO INTS
In patients with extensive skin loss and wound contracture, reexpansion has a high
ailure rate. Usually these patients are best served with the recruitment o new tis-
sue with a new blood supply. Loss o the IMF is always di f cult to correct. New
tissue placed at the location o the neo old is most likely to correct the problems.
An alternative solution is to use bilateral latissimus dorsi aps with new implants
or expanders. Fortunately, this patient had adequate abdominal tissue to re-create
both breasts. In patients who have a history o in ection, waiting an extended pe-
riod o time a ter device removal has a risk o recurrent in ection. This can be a re-
sult o biof lms in the wounds.
BIBLIO GRAPHY
Levine SM, Patel N, Disa JJ. Outcomes o delayed abdominal-based autologous reconstruction versus
latissimus dorsi ap plus implant reconstruction in previously irradiated patients. Ann Plast Surg
69:380-382, 2012.
Rabey NG, Lie KH, Kumiponjera D, et al. Salvage o ailed prosthetic breast reconstructions by autol-
ogous conversion with ree tissue trans ers. Eplasty 13:e32, 2013.
Tadiparthi S, Staley H, Collis N, et al. An analysis o the motivating and risk actors or conversion
rom implant-based to total autologous breast reconstruction. Plast Reconstr Surg 132:23-32,
2013.

40h Reconstruction With Free DIEP Flap
Mo u st a ph a h a md i
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 37-year-old woman presented with ailed bilateral implant breast reconstruc-
tion a ter mastectomies or bilateral breast cancer. She had chemotherapy and bi-
lateral radiotherapy. Two years a ter radiation treatments, bilateral expanders were
inserted. The reconstruction was complicated by in ection, and the le t expander
was removed a ter two unsuccess ul attempts. She was re erred to our department
or bilateral autologous breast reconstruction using deep in erior epigastric per ora-
tor aps (DIEPs). The patient had multiple risk actors (obesity, radiotherapy, and
chemotherapy). She did not smoke.
649

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
650
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a permanent implant on her right side with Baker grade III capsu-
lar contracture. Her skin is hyperpigmented, indicating a sequela o radiotherapy.
The implant is located retromuscularly on her right side. On the le t side the skin
is moderately contracted a ter removal o the expander, and the IMF is shi ted to a
higher position. Her axillary olds are preserved bilaterally.
ANALYSIS O F THE PRO BLEM
A ter an unsuccess ul breast reconstruction with an expander-implant in an irradi-
ated f eld, ap coverage is required. Another attempt to salvage the problem with
an implant will ail i good coverage with healthy well-vascularized tissue is not
f rst provided. To salvage the reconstruction, we chose a bilateral ree DIEP ap to
replace the implants.
RECOMMENDED SOLUTION TO THE PROBLEM
Undermining o the upper breast skin rom the pectoralis major muscle
Removal o the implant together with the anterior capsule, especially the por-
tion just beneath the lower breast skin
Preservation o the posterior capsule’s attachment to the thoracic wall, which
can be sutured to the IMF or used to reduce the size o the pocket
Fixation o the pectoralis major in its original anatomic position on the thoracic
wall
Splitting o the pectoralis major muscle at the level o the third intercostal space
to prepare the internal mammary vessels
DIEP ap harvest and placement under the breast skin

Chapter 40 • Failed Expander/Implant Reconstruction

651
TECHNIQ UE
The di erent anatomic structures were repositioned or reconstituted be ore a new
breast was reconstructed. The skin was separated rom the pectoralis major mus-
cle along the ootprint o the new, reconstructed breast. A ter removal o the pros-
thesis, we removed most o the anterior capsule and released all scar contractions,
especially in the region o the anterior axillary old. The pectoralis major muscle,
which is usually li ted by the retromuscular placement o the prosthesis, was repo-
sitioned to its original location. The muscle was resutured onto the posterior sheath
o the capsule. The IMF o ten needs to be reconstructed at this stage. The IMF was
re-created by suturing part o the anterior capsule or the superf cial ascia to the
posterior sheath o the capsule on the thoracic wall. Only this maneuver will re-
construct the actual ootprint o the breast, making it the ideal plat orm or urther
breast mound reconstruction.
Implant and
part of anterior
capsule removed
DIEP free flap
Original capsule
reused to form
new inferior
pocket and IMF
Pectoralis major
sutured to
posterior capsule

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
652
Bilateral DIEP aps were harvested in the standard manner. The internal mammary
vessels were prepared or microanastomosis. A ter the ap was trans erred, it was
shaped and the skin deepithelialized to achieve breast symmetry. The postoperative
course was unevent ul.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The abdominal wound was corrected approximately 1 year postoperatively. This
procedure was combined with bilateral nipple reconstruction under local anesthe-
sia. The patient is shown 2 years postoperatively. The reconstructed breasts were
supple and so t without urther complications; however, because o a lack o breast
skin, a patchy skin appearance resulted.

Chapter 40 • Failed Expander/Implant Reconstruction

653
TEACHING PO INTS
The overall complication rate o implant-based breast reconstructions is reported to
be as high as 40% and can reach 70% a ter radiotherapy. The most requent com-
plications are capsular contracture and in ection. From a technical point o view,
tertiary breast reconstructions are o ten di f cult procedures. The sequelae o pre-
vious surgeries and the requency o tissue damage a ter radiotherapy make these
patients poor candidates or implant-based reconstructions. I implants are used in
these di f cult secondary and tertiary cases, the likelihood o capsular contracture
with subsequent breast distortion is high. Bilateral pedicle latissimus dorsi aps
with or without implants can be an option or patients with hypercoagulability or
major damage to recipient vessels. In this case, the patient’s choice was consistent
with our pre erred method—bilateral breast reconstruction with ree trans er o
DIEP aps. The DIEP ap is the benchmark or autologous breast reconstruction,
because it provides ample tissue volume with low donor site morbidity. In this case,
the surgery not only salvaged a breast reconstruction, it was also a body contouring
procedure, and the patient greatly appreciated the outcome (see p. 652). We believe
that autologous tissue breast reconstruction is quite o ten the only way to obtain a
satis actory and natural-appearing result in tertiary breast reconstruction cases, be-
cause it restores anatomy and reconstructs volume with healthy, well-vascularized
tissue.
It is essential to create a ootprint or a newly reconstructed breast. A ter removal
o an implant, most o the anterior capsule (under the skin) should be removed.
However, the posterior sheath o the capsule is preserved or reinsertion o the
pectoralis major muscle and f xation o the IMF. The ap is placed under the skin
pocket. Total autologous tissue reconstruction should be considered whenever pos-
sible and indicated. Further correction with at gra ting or scar revision can be per-
ormed 3 to 6 months later.
BIBLIO GRAPHY
Disa JJ, Ad-El DD, Cohen SM, et al. The premature removal o tissue expanders in breast reconstruc-
tion. Plast Reconstr Surg 104:1662-1665, 1999.
Hamdi M, Blondeel P, Van Landuyt K, et al. Bilateral autogenous breast reconstruction using per ora-
tor ree aps: a single center’s experience. Plast Reconstr Surg 114:83-89, 2004.
Hammond DC. Latissimus dorsi ap breast reconstruction. Plast Reconstr Surg 124:1055-1063,
2009.
Losken A, Carlson GW, Schoemann MB, et al. Factors that in uence the completion o breast recon-
struction. Ann Plast Surg 52:258-261, 2004.
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.

40i Salvage of Failed Bilateral Expander Reconstruction
With Autologous Tissue Transfer
Gl y n Jo n es
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 42-year-old woman developed cancer o her le t breast that required a mas-
tectomy and subsequent radiotherapy. Her reconstructive surgeon placed interim
tissue expanders with the goal o expander-implant exchange a ter radiotherapy i
her skin envelope was so t enough and her shape acceptable. No ADM was placed.
A ter radiation treatment, her le t expander developed attenuated coverage with
erosion.
The expander was removed. The skin overlying her partially in ated right expander
also showed signs o thinning. She was re erred or a salvage procedure.
654

Chapter 40 • Failed Expander/Implant Reconstruction

655
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has severe hollowing o the central breast de ect with tethered, radiated
skin. The medial in erior mastectomy skin ap is extremely thin, while the lateral
skin is edematous, thick, and poorly compliant. The entire lower pole mastectomy
skin envelope is considered essentially unusable. The pectoralis major muscle is f -
brotic and tight. Upper mastectomy skin is more pliable and def nitely salvageable.
The in ramammary crease is obliterated. Her latissimus and TRAM ap donor sites
are both viable options, and she avors the TRAM ap option. While not radiated,
her right mastectomy skin ap is very thin without ADM support but appears sta-
ble. She has a airly long, thin chest. She requires the majority o her TRAM ap
donor site skin to resur ace the le t breast sur ace area.
ANALYSIS O F THE PRO BLEM
The expander in the patient’s right breast was intact and nonin ected, with thinning
skin at the 8 o’clock position. On her le t side, the irradiated explantation site was
healed, the lower pole mastectomy ap was edematous and contracted, and the me-
dial irradiated scar was very thin.
RECOMMENDED SOLUTION TO THE PROBLEM
Le t breast reconstruction with a TRAM ap
Creation o a bipedicle ap to meet the very large skin and volume requirement
Insertion o an allogra t over the right expander lower pole to attempt salvage
The patient’s irradiated skin was allowed to recover rom explantation. A bipedi-
cle TRAM ap was planned, because a large skin island was necessary to accom-
modate the D cup breast size that she desired. ADM insertion was planned or the
right side. The patient was advised that a latissimus ap might be necessary i this
ailed, because the skin was very attenuated. The skin on her right breast continued
to deteriorate, and eventually a small area o the implant pushed through the seam
between the ADM and the caudal border o the pectoralis muscle.
TECHNIQ UE
The patient underwent bipedicle TRAM ap reconstruction o the le t breast. The
patient was reluctant to proceed with ree TRAM or DIEP ap reconstruction
because o her concerns about operative duration. She healed unevent ully and
achieved a satis actory le t breast mound reconstruction, although the ap ailed
to achieve complete upper pole f ll because o a lack o tissue volume. Early in her
post-TRAM ap recovery, she un ortunately eroded her right expander skin en-
velope through the mastectomy incision at the 8 o’clock position. The skin qual-
ity was poor; there ore a right latissimus ap and implant reconstruction was
per ormed using an extended autologous approach with a round, smooth 325 cc

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
656
high prof le gel implant placement. This le t the patient with bilateral stable breast
mounds, with the le t side entirely autologous and the right side combining both
autologous and alloplastic techniques.
ANALYSIS O F THE PRO BLEM AFTER THE FIRST STAGE
The le t TRAM ap was stable and well healed. On her right side, the expander
was eroding at the 8 o’clock position, necessitating immediate salvage with autolo-
gous tissue. The patient had an adequate latissimus dorsi donor site on her right
side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS: FIRST STAGE
The patient is shown 1 month a ter le t TRAM ap reconstruction and subsequent
latissimus ap reconstruction several weeks later. She has a well-healed stable latis-
simus dorsi reconstruction o her right breast. Her latissimus donor site is shown
6 months a ter the procedure.
RECOMMENDED SOLUTION TO THE PROBLEM
Explantation on the right
Resection o attenuated mastectomy skin
Resur acing with a latissimus skin island
Insertion o a gel implant and coverage with the latissimus dorsi muscle

Chapter 40 • Failed Expander/Implant Reconstruction

657
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS: SECO ND STAGE
The patient desired a larger breast than her TRAM ap was able to provide. An
asymmetrical augmentation was per ormed beneath both aps, together with struc-
tural at gra ting to hollowing areas in the upper medial poles. She is shown 1 year
a ter nipple-areolar reconstruction. Further upper pole at injection would be bene-
f cial, but the patient is satisf ed and has declined this treatment. She was extremely
grate ul or the success o her salvage surgery and is pleased with her cosmetic out-
come.
Preoperative view of failed expander
reconstruction with irradiated tissue
First stage after latissimus dorsi
reconstruction
Final result after TRAM flap and nipple-areolar reconstruction

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
658
TEACHING PO INTS
Although this patient’s outcome was success ul, she required multiple major pro-
cedures to achieve the result. This case highlights the importance o gaining a pa-
tient’s conf dence during an arduous clinical course or both patient and surgeon.
Patience and care ully timed procedures that allow maturation o the wound and
resolution o edema are crucial to the success o these complex, staged reconstruc-
tions. In addition, this case graphically demonstrates how un orgiving irradiated
tissue can be even in a young, otherwise healthy patient.
The ollowing points are important to keep in mind when salvaging ailed bilateral
expander reconstruction with autologous tissue:

Ô Expander erosion is an extremely di f cult problem to resolve.

Ô Attempts at de ating expanders and resuturing attenuated skin envelopes
usually end in explantation.

Ô Radiated expanders have an extremely high complication rate.

Ô Salvage o these problems usually requires healthy autologous tissue trans er.
BIBLIO GRAPHY
Ascherman JA, Hanasono MM, Newman MI, Hughes DB. Implant reconstruction in breast cancer
patients treated with radiation therapy. Plast Reconstr Surg 117:359-365, 2006.
Berry T, Brooks S, Sydow N, et al. Complication rates o radiation on tissue expander and autologous
tissue breast reconstruction. Ann Surg Oncol 17(Suppl 3):S202-S210, 2010.
Christante D, Pommier SJ, Diggs BS, et al. Using complications associated with postmastectomy ra-
diation and immediate breast reconstruction to improve surgical decision making. Arch Surg
145:873-878, 2010.
Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant
breast reconstruction: part I. A prospective analysis o early complications. Plast Reconstr Surg
118:825-831, 2006.
Disa JJ, McCarthy CM. Breast reconstruction: a comparison o autogenous and prosthetic techniques.
Adv Surg 39:97-119, 2005.
Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review o the litera-
ture. Plast Reconstr Surg 124:395-408, 2009.
Moran SL, Herceg S, Kurtelawicz K, Serletti JM. TRAM ap breast reconstruction with expanders
and implants. AORN J 71:354-362; quiz 363-368, 2000.

40j Implant Exposure After Nipple Reconstruction:
Correction With Implant Replacement and Latissimus
Dorsi Flap
Al l en Ga br iel , G. Pa t r ic k Ma x w el l
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old woman presented a ter a recent diagnosis o le t breast invasive
lobular carcinoma, which was diagnosed rom a biopsy specimen. MRI demon-
strated a right breast mass. A biopsy o this lesion conf rmed bilateral lobular carci-
noma. She was otherwise healthy and had quit smoking be ore her mastectomy. She
was scheduled or a bilateral mastectomy with immediate reconstruction.
The approach or the mastectomy was per ormed through bilateral IMF incisions.
The nipple and most o the areola were removed. Immediate reconstruction in-
cluded placement o 133mV 300 cc expanders (60 cc in each expander) and acellu-
lar dermal matrix (ADM) (AlloDerm; Li eCell, Branchburg, NJ). All incisions were
closed with 3-0 Vicryl, 4-0 Vicryl, and 4-0 Monocryl.
659

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
660
The patient had an unevent ul surgical course. She had adjuvant chemotherapy ol-
lowed by bilateral chest radiotherapy.
A ter the completion o her radiotherapy, expansion was started. The expanders
were f lled to a f nal volume o 300 cc. One year a ter the completion o radiother-
apy, bilateral Style 20 375 cc implants (Allergan, Irvine, CA) were placed with addi-
tional ADM (Strattice; Li eCell).

Chapter 40 • Failed Expander/Implant Reconstruction

661
The patient continued to do well. Six months a ter implant placement, her nipples
were reconstructed using modif ed skate aps. Three weeks postoperatively, she
presented with increasing drainage rom her le t breast. The reconstructed nipple
was completely necrosed, and the ADM and implant were exposed. Primary closure
o this in amed, irradiated tissue will not yield the desired result. Autologous tissue
was needed. From our experience, the addition o a latissimus ap while an implant
is in place is at times complicated, particularly when the skin is in amed and has
decreased expandability. The use o vascularized tissue to resur ace the inner pocket
was considered.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has necrosis with exposure o her ADM and implant nearly 3 weeks
a ter nipple reconstruction. She did well a ter all o her prior procedures. She is a
healthy nonsmoker and desires salvage o her breast. Because her BMI is 18.5, her
tissues are insu f cient or a completely autologous reconstruction.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
662
ANALYSIS O F THE PRO BLEM
Breast reconstruction with implants a ter radiotherapy continues to pose a big chal-
lenge to plastic surgeons. The two Ps o radiation (progressive and permanent)
must be kept in mind when tackling these complicated problems, because irradi-
ated tissues behave di erently rom nonirradiated tissues. The creation o a breast
mound that is so t and aesthetically pleasing is a complicated process in irradiated
patients. This patient had bilateral chest wall radiotherapy with expanders in place.
Early expansion a ter irradiation helps to create a so t tissue envelope or place-
ment o an implant. In light o the unpredictable nature o irradiated skin, should
nipple reconstruction be avoided on irradiated breast mounds? The answer depends
on multiple variables, including laxity o the skin and thickness o the skin enve-
lope. Could the injection o at ahead o time possibly have prevented this patient’s
complication?
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the implant
Placement o an expander
Replacement o the expander with an implant
Coverage with a latissimus ap
TECHNIQ UE
The goal o this surgery was to resur ace the inner pocket with vascularized tissue
to enhance expansion. Preoperatively the patient was in ormed that an expander
would be reinserted. The expander was placed or 4 months be ore the placement
o the permanent implant. This is done to acilitate the development o new vascu-
larized tissue to support the so t tissue envelope and maintain expansion a ter tis-
sues are healed. New, well-vascularized skin aps then will be available to serve as
a receptive environment or an implant.

Chapter 40 • Failed Expander/Implant Reconstruction

663
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS: SECO ND STAGE
The patient is shown 6 months a ter implant replacement on her le t side. This case
raises the question o whether or not nipples should be reconstructed on irradiated
mastectomy aps. Is it worth the risk, and is the aesthetic result satis ying to both
surgeon and patient? The ADM provided some temporary implant coverage until
the problem was corrected. At the time o surgery, no uid or purulence was pres-
ent. In ection would have complicated the management o this case. This is an ex-
ample o the unpredictability o irradiated breasts. Care ul ollow-up is important
in this patient population.
TEACHING PO INTS
Complications related to irradiated skin aps should be treated aggressively, always
with the goal o supplying the area with well-vascularized tissue. Complications
rom radiotherapy are usually seen 3 to 4 weeks postoperatively, because they are
related to delayed necrosis o poorly vascularized tissue.
BIBLIO GRAPHY
Cordeiro PG, Pusic AL, Disa JJ, et al. Irradiation a ter immediate tissue expander/implant breast re-
construction: outcomes, complications, aesthetic results, and satis action among 156 patients.
Plast Reconstr Surg 113:877-881, 2004.
de Oliveira RR, Pinto e Silva MP, Gurgel MS, et al. Immediate breast reconstruction with transverse
latissimus dorsi ap does not a ect the short-term recovery o shoulder range o motion a ter
mastectomy. Ann Plast Surg 64:402-408, 2010.
McCarthy CM, Pusic AL, Disa JJ, et al. Unilateral postoperative chest wall radiotherapy in bilateral
tissue expander/implant reconstruction patients: a prospective outcomes analysis. Plast Reconstr
Surg 116:1642-1647, 2005.
Nahabedian MY. AlloDerm per ormance in the setting o prosthetic breast surgery, in ection, and ir-
radiation. Plast Reconstr Surg 124:1743-1753, 2009.

(Trang không có chữ)

SEC T IO N T WO
Suboptimal Aesthetic Outcomes
Chapter 41 Asymmetry
41a Fat Gra ting
41b Correction With Implant Exchange, Capsulotomy, and Pocket Adjustment
41c Capsulorrhaphy With In erior Skin Recruitment and Implant Exchange
Chapter 42 Unsatisfactory Shape or Contour
42a Unilateral TRAM Flap
42b Correction o Tissue Breakdown and Failed Tissue Expansion Reconstruction
Using Rigottomies, Brava External Expansion, and Serial Lipo lling
42c Fat Gra ting
665

(Trang không có chữ)

C h APT Er 4 1
ASYMMETRY
41a Fat Grafting
Emma n u el Del ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 53-year-old woman complained o a breast de ormity a ter implant breast re-
construction. She was especially concerned about asymmetry in the upper quadrant
o her le t breast that she considered incapacitating and that a ected her personal
li e.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has three major limitations associated with implant breast reconstruc-
tion: (1) so t tissue de ormities in the sternum area with asymmetry between her
breasts, (2) inner de ects with capsular contracture and exaggerated breast cleav-
age, and (3) external de ects with a depression on the sur ace o her le t breast, just
under the anterior axillary old. Furthermore, she reports that her breast is uncom-
ortable because o the hardness associated with capsular contracture.
667

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
668
ANALYSIS O F THE PRO BLEM
This patient had noticeable so t tissue de ormities in her sternum area as a result o
her implant breast reconstruction. The implant edges were visible in the upper part
o her le t breast, and her breasts were asymmetrical. On her le t breast, she also
had capsular contracture, which de ormed her breast and exaggerated her cleavage,
and depressions were evident on the sur ace, just under the anterior axillary old.
Based on the avorable results obtained with at gra ting a ter autologous latissi-
mus dorsi f ap reconstruction, we decided to apply the same technique to manage
this patient’s so t tissue de ormities.
RECOMMENDED SOLUTION TO THE PROBLEM
Implant replacement
Placement o 145 cc o re ned at in the upper inner quadrant o the breast
TECHNIQ UE
We decided to replace the prosthesis in her le t breast and per orm at gra ting re-
construction, with placement o 145 cc o re ned at in the upper inner quadrant o
the patient’s breast.
Fat is generally trans erred over the implant edge onto the sternum, principally in
the pectoralis major muscle. This patient underwent at gra ting concurrently with
prosthesis replacement. The at was harvested on the thighs, and processed with a
short centri ugation. Fatty tissue was trans erred between the capsule and the skin.
The volume o at gra ted was small (145 cc), because the surrounding tissues were
less vascularized than in an autologous latissimus dorsi f ap. Less atty tissue helped
to ensure success ul gra t take. No at gra ting–related complications occurred.
Usually it is better to harvest more at than the expected quantity to trans er. We
pre er to gra t at with the old implant in place to prevent trauma to the new one.

Chapter 41 • Asymmetry

669
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
One year later, the patient has maintained an excellent aesthetic result, particularly
in the sternum area, which was the principal ocus o the intervention. The cleavage
area is dramatically improved, and the patient has gained con dence in her social
li e. The reconstructed breast has the desired so tness, and the patient is much more
com ortable.
TEACHING PO INTS
The spaghetti box concept is important and help ul or determining the volume o
at that can be gra ted to the breast. According to this notion, the receiving tissues
are assimilated as a spaghetti box. It is important to learn to evaluate the volume o
the receiving tissues to evaluate the volume to trans er. I tissues are very thin, the
at trans er can be very limited. I more thickness is required, a session o lipomod-
eling is completed, and 3 months later another session o lipomodeling and implant
exchange are per ormed in the same procedure.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
670
BIBLIO GRAPHY
Delay E. Lipomodeling o the reconstructed breast. In Spear SE, ed. Surgery o the Breast: Principles
and Art, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2010.
Delay E, Delpierre J, Sinna R, et al. [How to improve breast implant reconstructions?] Ann Chir Plast
Esthet 50:582-594, 2005.
Ho Quoc C, Sinna R, Gourari A, La Marca S, Toussoun G, Delay E. Percutaneous asciotomies and
at gra ting: indications into breast surgery. Aesthet Surg J 33:995-1001, 2013.