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

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
672
A le t mastectomy and expander reconstruction with an ADM were per ormed.
A ter 2 months o expansion bilaterally, both tissue expanders were removed and
replaced by 250 cc smooth round moderate pro le implants. Her results are shown.
Despite lowering o her right IMF, her breasts had signi cant asymmetry.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s right breast mound is higher than her le t mound, with the right im-
plant positioned higher. The right skin envelope is tighter. The irradiated right
breast implant is relatively so t. Some brosis o the skin envelope is present on the
right side; however, the shape is acceptable. Her le t IMF has a more natural de-
scent, and her le t skin envelope is so t, with the pocket larger than the implant.
Lateral displacement o the implant is noticeable when she is supine.

Chapter 41 • Asymmetry

673
ANALYSIS O F THE PRO BLEM
The irradiated right breast will not age as naturally as the le t breast. Although the
mound was slightly higher on the right than pre erred, the implant was so t; the
shape was relatively natural, with acceptable lower pole ptosis and good de nition
o the IMF. Because this breast was previously irradiated, a decision was made not
to manipulate this side. Instead, the opposite side will be adjusted to improve sym-
metry. The le t breast pocket was larger than the implant, and the IMF was lower.
RECOMMENDED SOLUTION TO THE PROBLEM
Le t implant exchange and capsulotomy
Le t IMF elevation
Tightening o the le t lateral mammary old
Right nipple reconstruction
TECHNIQ UE
The patient was placed in a supine position and marked preoperatively to de ne
the IMF and nipple positions. The previous le t mastectomy incision was opened.
The implant was removed, and a capsulotomy was per ormed superiorly and medi-
ally to provide space to mobilize the implant appropriately. An incision in the cap-
sule was made just above the IMF level.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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A capsular f ap was then elevated to the level o the IMF. The f ap was made as
thick as possible. This was per ormed along the length o the IMF. The in erior ex-
tent o dissection was at the level o the IMF-skin junction. Clamps were placed on
the capsular f ap and it was pulled superiorly, elevating the position o the IMF. The
desired amount o elevation was determined and marked on the chest wall. The
capsular f ap was then secured to the chest wall above the level o the IMF with
multiple 0 Prolene sutures and a running 0 Vicryl stitch. A capsulorrhaphy was
per ormed in a similar ashion laterally. The right nipple was reconstructed using a
C-V f ap. Le t nipple reconstruction was de erred given the amount o mound ad-
justment. Postoperatively the IMF was taped, and the patient was placed in a sup-
portive bra.

Chapter 41 • Asymmetry

675
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 6 months a ter IMF correction. Her breast mounds have good
symmetry, with her IMFs in satis actory positions. Her breasts are so t, and she is
aware o the increased risk o tightening rom capsular contracture on her right
side. Le t nipple reconstruction and bilateral nipple-areolar tattoos are planned.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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TEACHING PO INTS
Accurate and symmetrical IMF positioning is one o the more important aspects o
creating an aesthetic result a ter postmastectomy breast reconstruction. Textured
expanders are thought to preserve the location o the IMF during the expansion
process. Ideally, the IMF position is determined and ensured at the original recon-
struction. However, it occasionally becomes distorted. In this case, it was lower
relative to the opposite, irradiated breast. Many di erent techniques have been
described to re ne the IMF. Whether the old is raised or dropped, accurate and
secure xation o the new old to the chest wall is critical. Occasionally, the entire
old needs to be re-created, which is more challenging. This patient’s old was pres-
ent but low. Elevation can be achieved through an external approach or through
the capsule. The external approach relies on accurate xation to the chest wall
with either a deepithelialized f ap o subcutaneus tissue, ensuring dermal xation
with the skin f ap. The position o the IMF varies, based on the contralateral side,
but is usually at the level o the th or sixth rib. Strong xation is critical and usu-
ally involves anchoring to the periosteum. It is o ten pre erable to approach the
old through the capsule in implant reconstructions, because it allows opening o
the capsule superiorly without additional scars to the breast mound. Numerous
techniques have been described to reliably maintain the shape, including the use o
metal pins and barbed sutures. Simple capsulorrhaphy o ten will result in descent i
the capsule is not strong enough and pressure is placed directly on the suture line.
Tension can be redistributed using ADM products, which urther rein orce the re-
construction and possibly reduce the incidence o capsular contractures. These are
used in recurrent and more complex de ormities. Adequate xation is especially im-
portant with larger implants, given the additional weight and size. This technique
o xation allows elevation o a healthy capsular f ap, control over the level, and
xation onto the chest wall away rom the in eriormost aspect or control o the
level itsel . These actors should minimize the risk o recurrence.
Radiotherapy will signi cantly change the long-term result in implant-based breast
reconstructions. The risk o capsular contracture, skin brosis, and elevation o the
IMF is higher on the irradiated side. It is occasionally not possible to continue with
implant reconstruction in irradiated patients, and conversion to autologous recon-
struction is required. However, when implants can be used a ter radiotherapy, as in
this case, potential adverse outcomes need to be anticipated and the technique ad-
justed to ensure success and adequate long-term symmetry.

Chapter 41 • Asymmetry

677
BIBLIO GRAPHY
Chun YS, Pribaz JJ. A simple guide to in ramammary- old reconstruction. Ann Plast Surg 55:8-11; dis-
cussion 11, 2005.
Fan J, Raposio E, Wang J, et al. Development o the in ramammary old and ptosis in breast recon-
struction with textured tissue expanders. Aesthetic Plast Surg 26:219-222, 2002.
Hester TR Jr, Ghazi BH, Moyer HR, et al. Use o dermal matrix to prevent capsular contracture in
aesthetic breast surgery. Plast Reconstr Surg 130(5 Suppl 2):S126-S136, 2012.
Kronowitz SJ. Current status o implant-based breast reconstruction in patients receiving postmastec-
tomy radiation therapy. Plast Reconstr Surg 130:513e-523e, 2012.
Wechselberger G, Del Frari B, Pülzl P, et al. In ramammary old reconstruction with a deepithelialized
skin f ap. Ann Plast Surg 50:433-436, 2003.

41c Capsulorrhaphy With Inferior Skin Recruitment
and Implant Exchange
Gl y n Jo n es
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
Asymmetry a ter immediate bilateral implant reconstruction can be problematic
because o di erences in the size and shape o the mastectomy pocket. This is par-
ticularly true when the IMF has been breached by the oncologic surgeon per orm-
ing the mastectomies. Failure to address these contour irregularities at the time o
immediate implant placement can lead to signi cant postoperative asymmetry, and
correction can be challenging.
This 60-year-old woman underwent bilateral skin-sparing mastectomies, the right
or breast cancer and the le t prophylactically. Reconstruction was per ormed with
gel implants. From the outset her reconstructions were asymmetrical, and she ound
it di cult to wear a bra; the strap slid up over the breast mound on the right side.
There ore she requested revision.
678

Chapter 41 • Asymmetry

679
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The breast implant on the right sits lower on the chest wall with a lower in ramam-
mary crease than that on the le t. The original mastectomy has le t residual breast
tissue on the right lower mastectomy ap and has created an impression o pseudo-
ptosis. The right breast implant has olded to create an implant knuckle beneath the
lateral mastectomy dog-ear, and the thin mastectomy skin is very attenuated. The
distance rom the IMF to the nipple is 13 cm on the right and 8 cm on the le t. The
le t breast implant sits higher on the chest wall, with grade III capsular contracture
and a higher in ramammary crease than that on the right. Skin quality in the lower
poles is acceptable. The implants are located in the subpectoral plane with rela-
tively minimal skin animation during muscle activity. Adjacent chest wall and ab-
dominal skin is so t and supple.
ANALYSIS O F THE PRO BLEM
The implant on the right side is too low, with a large lateral dog-ear. The in ramam-
mary crease on the le t side is ill def ned and too high, and the le t breast is too
small. The breast prof le is attened bilaterally.
RECOMMENDED SOLUTION TO THE PROBLEM
Le t open capsulotomy with implant exchange
Bilateral internal capsulorrhaphies with in erior skin recruitment
Implant exchange or high prof le gel implants
Revision o the right dog-ear
TECHNIQ UE
The patient underwent a le t open capsulotomy to lower the le t breast crease 2 cm.
A modif ed Ryan procedure involving undermining o the upper abdominal wall to
allow skin recruitment into the lower pole was per ormed. The upper abdominal
skin was li ted in a cephalad direction with suture f xation o the deep dermis to the
periosteum o the sixth rib with 0-Ethibond sutures. An implant exchange to high
prof le round smooth gel devices was per ormed. On the right side, a similar modi-
f ed Ryan procedure was per ormed, this time elevating the IMF 1 cm and suturing
it to the sixth rib periosteum as described or the le t side. Implant exchange was
similarly per ormed, along with the lateral mastectomy dog-ear. The nipple recon-
structions were not altered in any way. Using these techniques, the f nal distance
rom the nipple to the IMF was 10 cm on the right and almost 9 cm on the le t,
with a better appearance o lower pole ullness and a more def ned breast crease
bilaterally.

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
The patient is shown 6 months postoperatively. Her breasts are so t and supple
with grade I capsules. Although not per ect, her symmetry is improved and her
breast creases are better de ned. She is able to wear a bra com ortably and her
breast projection is improved, enabling her to look more eminine in clothing.

Chapter 41 • Asymmetry

681
TEACHING PO INTS
Restoration o identical breast crease location is essential to provide a stable plat-
orm or shape revision. Deepening o the IMF with a modi ed Ryan approach can
provide a secure location or a bra and prevent it rom riding up over the lower
pole o the breast. Matching the IMF-nipple distance as closely as possible restores
the aesthetic balance o the breast. Re-creating a stable, secure IMF position is a
di cult task requiring solid nonabsorbable suture xation; this can be dramatically
improved with ADM use.
BIBLIO GRAPHY
Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and in erolateral
AlloDerm slings. Ann Plast Surg 55:232-239, 2005.
Fan J, Raposio E, Wang I, Nordstrom RE. Development o the in ramammary old and ptosis in breast
reconstruction with textured tissue expanders. Aesthetic Plast Surg 26:219-222, 2002.
Goodwin SJ, McCarthy CM, Pusic AL. Complications in smokers a ter postmastectomy tissue ex-
pander/implant breast reconstruction. Ann Plast Surg 55:16-19; discussion 19-20, 2005.
Wechselberger G, Del Friari B, Pulzl P, Schoeller T. In ramammary old reconstruction with a deepithe-
lialized skin f ap. Ann Plast Surg 50:433-436, 2003.

(Trang không có chữ)

C h a p t e r 4 2
UNSATISFACTORY SHAPE
OR CONTOUR
42a Unilateral TRAM Flap
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 46-year-old woman had a previous breast reconstruction with an expander
and implant 6 years previously. She presented with a high-riding laterally displaced
implant. There was no IMF, she had a transverse scar, and she complained o the in-
ability to wear clothing because o the implant position. The patient described di -
culty during her original expansion and stated that the implant had been sitting
high and laterally since immediately a ter it was placed. Her goal was improved
symmetry as well as elevation o her le t ptotic breast.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s implant is displaced superiorly and is sitting laterally beyond the an-
terior axillary old. There is complete absence o an IMF, no projection, and the
majority o the volume o the implant is projecting toward the patient’s axilla and
clavicle.
683

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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The original mastectomy scar is obliquely placed along the lower portion o the
breast mound.
ANALYSIS O F THE PRO BLEM
There were many limiting actors with this patient’s situation. It was obvious that
the original expansion had never success ully created a breast mound, nor had the
expander ever been seated in a proper location. Most o the expansion appears to
have migrated out laterally toward the patient’s axilla and lateral chest wall with
no expansion either in eriorly or medially. Placing an implant in this patient’s ex-
panded pocket was a solution doomed to ailure. The other limiting actor is that
the original mastectomy scar obliquely transversed the bottom o the expanded
mound, which probably compromised the original expansion.
RECOMMENDED SOLUTION TO THE PROBLEM
Bringing in new autologous tissue, which is critical because any urther attempts
at tissue expansion are unlikely to correct this patient’s problem
Two equally viable solutions:
– TRAM f ap
– Latissimus dorsi f ap with an implant
Using a TRAM f ap without the need o any device, because this patient has so
many problems with a previous implant and a TRAM f ap is more likely to cre-
ate symmetry

Chapter 42 • Unsatisfactory Shape or Contour

685
TECHNIQ UE
In the operating room, using the contralateral IMF as a re erence point, a new IMF
was outlined on the patient’s right side. The actual incision was then made sev-
eral centimeters superior rom where the abdominal skin in this type o case would
probably retract in eriorly. A traditional unilateral pedicle TRAM f ap was used to
re-create the lower pole o the breast as well as the IMF. The original mastectomy
scar was ignored, and can be seen sitting several centimeters parallel to and above
the f ap inset site. In a second stage, a mastopexy was per ormed on the patient’s
le t side and NAC reconstruction on the right side.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Although this patient obtained a signi cant improvement, there is one obvious
shortcoming in her result: an inadequate medial IMF was created on the TRAM
f ap side. Initially, immediately a ter the surgery, the TRAM f ap seemed to be sit-
ting in good position, creating the entire IMF.
Incision for
new IMF
TRAM flap skin
island creates
lower pole
of new IMF
Contralateral
breast mastopexy

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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However, at ollow-up several years later, it can be seen that the old migrated in e-
riorly beyond the domain o the f ap. This occasionally happens as a result o tis-
sue relaxation over time. Overall, the patient has good symmetry regarding volume,
NAC location, and slopes o both reconstructed breasts.

Chapter 42 • Unsatisfactory Shape or Contour

687
TEACHING PO INTS
I expansion is unsuccess ul, inserting an implant is not going to provide a satis ac-
tory result. When there is a complete lack o tissue in the lower hal o a previously
expanded breast mound, autologous tissue is the best choice.
BIBLIO GRAPHY
Christensen BO, Overgaard J, Kettner LO, et al. Long-term evaluation o postmastectomy breast re-
construction with the pedicled transverse rectus abdominis musculocutaneous f ap. J Plast Surg
Hand Surg 47:374-378, 2013.
Davidge KM, Brown M, Morgan P, et al. Processes o care in autogenous breast reconstruction with
pedicled TRAM f aps: expediting postoperative discharge in an ambulatory setting. Plast Recon-
str Surg 132:339e-344e, 2013.
Duggal CS, Grudziak J, Metcal e DB, et al. The e ects o breast size in unilateral postmastectomy
breast reconstruction. Ann Plast Surg 70:506-512, 2013.
Park SU, Shim JS. Assessment o breast volume change a ter transverse rectus abdominis myocutane-
ous f ap. Arch Plast Surg 39:631-635, 2012.
Tan S, Lim J, Yek J, et al. The deep in erior epigastric per orator and pedicled transverse rectus abdo-
minus myocutaneous f ap in breast reconstruction: a comparative study. Arch Plast Surg 40:187-
191, 2013.

42b Correction o Tissue Breakdown and Failed Tissue
Expansion Reconstruction Using Rigottomies, Brava
External Expansion, and Serial Lipof lling
r o g er K. Kh o u r i
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This slender 32-year-old woman with a BMI o 18 had a massive tissue breakdown
a ter tissue expansion reconstruction. Her plastic surgeon attempted to salvage the
reconstruction and close the open chest wound with a latissimus dorsi f ap, but the
result was an aesthetic disaster; the f ap ended up looking like a old or indentation
on her chest wall. She was healthy with no history o smoking or diabetes.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s tissues are still inf amed, and she has an open wound that has been
treated with negative-pressure wound therapy (NPWT) or many months. She has
no breast projection and poor so t tissue coverage.
ANALYSIS O F THE PRO BLEM
This patient needed to have the unsightly skin f ap paddle old ironed out, the NAC
brought into a more normal position, and autologous tissue supplied or the recon-
struction. She was not a candidate or an abdominal f ap, a TRAM f ap, or a DIEP
f ap. The only alternative was external expansion and serial at gra ting to address
the de ormity while restoring her breast volume and shape.
688

Chapter 42 • Unsatisfactory Shape or Contour

689
RECOMMENDED SOLUTION TO THE PROBLEM
For her right breast:
Percutaneous needle mesh release, known as a “Rigottomy,” and Brava ex-
ternal expansion
Three serial at gra ting procedures to ll out the f ap old and recreate a
breast mound
Excision o the useless latissimus dorsi f ap skin paddle and advancement o
the regenerated skin over the excised skin f ap to centralize the nipple and
provide a totally autologous breast reconstruction
For her le t breast:
Replacement o the contracted breast implant with a smaller implant
Fat gra ting around the new implant to create a more natural appearance
and to reduce the potential or capsular contracture
TECHNIQ UE
The salvage required a series o our di erent procedures over an 8-month span.
Three sessions involved Rigottomy scar release and at gra ting; each session was
preceded by Brava expansion or at least 3 weeks to smooth out the skin old and
to regenerate the patient’s breast mound. In a ourth procedure the useless skin
paddle o the latissimus dorsi f ap was excised and the regenerated skin advanced
to redrape over the paddle de ect to provide the patient with a totally autologous
breast reconstruction. The only new incision made was to excise the skin paddle.
At the time o skin paddle resection, the contracted and de ormed implant in her
le t breast was replaced with one that was hal the size o the previous implant. Fat
was then gra ted all around the implant to reduce the potential or contracture and
to provide a so t, natural result.
The patient is shown 4 days a ter the rst procedure. This was the rst stage a ter
Rigottomy and at trans er. Notice the minimal volume gain at this stage, with ex-
tensive needle pricks, or Rigottomies, to release the scar and to make room or the
at gra ting.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
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Two months later, the patient came to the operating suite or her second gra t-
ing session. She had been wearing the Brava expander or about 10 hours per day
or the previous month. Note the marked hyperemia and the degree o expansion
caused by the vacuum.
The Brava expander was removed just be ore the patient entered the operating
room. Notice the volume gain induced by the Brava expander; the volume gain was
temporary and would subside unless at gra ting was per ormed immediately.
Tumescent lipo lling o the expanded breast
placed the residual brous scars under tension;
these scars were then released with Rigottomies.
The cannula was used to measure interstitial tis-
sue pressure and to help determine when to stop
gra ting to avoid overgra ting, which is counter-
productive. Note the serosanguineous drainage
rom the Rigottomy sites.

Chapter 42 • Unsatisfactory Shape or Contour

691
The patient is shown 4 days a ter the Rigottomy and lipo lling. Some volume in-
crease o the breast mound is evident, with some f attening o the old.
Two months later, which included 1 month o Brava expansion, the patient has ur-
ther volume gain and more stretching and more f attening o the old.
The patient is shown 4 days a ter the third at gra ting session, when extensive
Rigottomies were per ormed again to urther release the ne individual scar bands
one by one with the needle and create a sca old or at gra ting.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
692
Three months later, the breast was so t and had the consistency o normal at. The
breast mound was restored with three sessions o at gra ting.
The skin paddle was no longer necessary, and we needed to centralize the NAC.
These steps were per ormed in a ourth procedure. This was the only procedure
that required an incision to excise the skin paddle and elevate the breast f ap to re-
veal normal-looking underlying at and then to redrape the breast. In the same pro-
cedure, we exchanged her le t cosmetic implant or a smaller prosthesis and gra ted
at to ll out the tissue laxity that resulted rom downsizing the implant.
The patient is shown 1 year postoperatively. She had a total autologous breast
reconstruction with Brava expansion and at gra ts. Her breasts were so t, they
looked and elt natural, and the reconstructed breast was partially sensate.

Chapter 42 • Unsatisfactory Shape or Contour

693
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown preoperatively a ter 3 Rigottomies, Brava expansion, and au-
tologous at gra ting procedures, and then 2 weeks postoperatively a ter skin pad-
dle excision, breast f ap elevation, and NAC centralization on the right breast and
implant exchange and at gra ting on the le t breast. This procedure provided the
patient with a so t, natural breast reconstruction.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
694
TEACHING PO INTS
A whole new concept and approach is described; this novel approach combines
Rigottomy, external Brava expansion, and serial at gra ts. This approach is a pow-
er ul tool that can regenerate a breast mound even a ter previous attempts have
ailed. Even in a patient with a BMI o 18, we were able to nd enough at to re-
construct this breast.
Key to this technique is minimal centri ugation o the lipoaspirate. Through the
Rigottomy procedure, the lipoaspirate is then gra ted with a large percentage o
f uid to put the restrictive brous scars under tension so that they can be individu-
ally released percutaneously with the needle tip. This crucial maneuver generates
the necessary space and the brovascular sca old required, leading to better disper-
sion o individual at droplets, better gra ting to the recipient inter ace, and better
survival o the precious at.
Gra t survival is optimized in a well-prepared recipient sca old. But it is important
to avoid overgra ting. It is critical to recognize the gra ting capacity o the tissue.
Once the recipient is ull, the more gra ting per ormed, the worse the tissue gets.
Interstitial pressure monitoring is e ective in determining the maximal lling pres-
sure. We like to keep the pressure below 10 mm Hg.
Rigottomies turn the restrictive cicatrix into a recipient matrix or at gra ting. The
at gra ts survive inside the tiny interstices generated by the meticulous micromesh-
ing o the scar tissue block. When releasing the scar with the Rigottomies, which
turns the scar into brous sca old, care should also be taken to avoid overrelease.
Overreleasing destroys the sca old and leads to a cavity, which is the enemy o at
gra ts. A sa e surgery involves multiple stages, and we can only do so much at each
stage. Fortunately, the surgery is minimally invasive, involves no incision, and has a
quick recovery.
Brava external expansion is crucial to this procedure, because it increases vascular-
ity, keeps the gra ted spaces open, and urther expands the sca old and skin enve-
lope in preparation or the next gra ting session. External expansion also improves
the recipient site or better survival o the at. Rigottomy releases are also appropri-
ate or treating Dupuytren contracture. They mesh-expand the contracted Dupuy-
tren cord to turn it into a recipient sca old where the at gra t can survive.

Chapter 42 • Unsatisfactory Shape or Contour

695
BIBLIO GRAPHY
Baran CN, Celebiog˘lu S, Sensöz O, et al. The behavior o at gra ts in recipient areas with enhanced
vascularity. Plast Reconstr Surg 109:1646-1651; discussion 1652, 2002.
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Quality Medical
Publishing, 2009.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
119:775-785; discussion 786-787, 2007.
Delay E. Correction o partial breast de ormities with the lipomodeling technique. In Kuerer H, ed.
Kuerer’s Breast Surgical Oncology. New York: McGraw-Hill, 2010.
Delay E. Lipomodeling o the reconstructed breast. In Spear SE, ed. Surgery o the Breast: Principles
and Art, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
Delay E. Reconstruction o breast de ormities. In Coleman SR, Mazzola RF, eds. Fat Injection: From
Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
Gusset J, Flageul G, Toussoun G, Guerin N, Tourasse D, Delay E. [Lipomodeling or correction o
breast conservative treatment sequelae. Medicolegal aspects. Expert opinion on ve problematic
clinical cases] Ann Chir Plast Esthet 53:190-198, 2008.
Hovius SE, Kan HJ, Smit X, Selles RW, Cardoso E, Khouri RK. Extensive percutaneous aponeurotomy
and lipogra ting: a new treatment or Dupuytren disease. Plast Reconstr Surg 128:221-228, 2011.
Khouri RK. Breast augmentation and reconstruction with Brava external expansion and at gra ting:
prospective study update. Presented at the Annual Meeting o the American Society o Aesthetic
Plastic Surgery, San Diego, May 2008.
Khouri RK, Del Vecchio DA. Breast reconstruction and augmentation with Brava external expansion
and at gra ting. In Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St
Louis: Quality Medical Publishing, 2009.
Khouri RK, Eisenmann-Klein M, Cardoso E, et al. Brava and autologous at trans er is a sa e and e -
ective breast augmentation alternative: results o a 6-year, 81-patient, prospective multicenter
study. Plast Reconstr Surg 129:1173-1187, 2012.
Khouri RK, Schlenz I, Murphy BJ, et al. Nonsurgical breast enlargement using an external so t-tissue
expansion system. Plast Reconstr Surg 105:2500-2512; discussion 2513-2514, 2000.
Khouri RK, Smit JM, Cardoso E, et al. Percutaneous aponeurotomy and lipo lling: a regenerative al-
ternative to f ap reconstruction? Plast Reconstr Surg 132:1280-1290, 2013.
Kurita M, Matsumoto D, Shigeura T, et al. Inf uences o centri ugation on cells and tissues in liposuc-
tion aspirates: optimized centri ugation or lipotrans er and cell isolation. Plast Reconstr Surg
121:1033-1041; discussion 1042-1043, 2008.
Missana MC, Laurent I, Barreau L, et al. Autologous at trans er in reconstructive breast surgery: in-
dications, technique and results. Eur J Surg Oncol 33:685-690, 2007.
Pierre eu-Lagrange AC, Delay E, Guerin N, et al. [Radiological evaluation o breasts reconstructed
with lipomodeling] Ann Chir Plast Esthet 51:18-28, 2006.
Rietjens M, De Lorenzi F, Petit JY. Secondary breast reconstruction. In Coleman SR, Mazzola RF, eds.
Fat Injection: From Filling to Regeneration. St Louis: Quality Medical Publishing, 2009.
Rigotti G, Marchi A, Baroni G. Structural at gra ting or the regeneration o irradiated tissue. In
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Quality
Medical Publishing, 2009.
Smith CJ, Khouri RK, Baker TJ. Initial experience with the Brava nonsurgical system o breast en-
hancement. Plast Reconstr Surg 110:1593-1595; author reply 1595-1598, 2002.
Spear SE, Wilson HB, Lockwood MD. Fat injection to correct contour de ormities in the reconstructed
breast. Plast Reconstr Surg 116:1300-1305, 2005.
Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg 32:313-328, 2008.

42c Fat Gra ting
Sy d n ey r . Co l ema n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 46-year-old patient presented 21⁄2 years a ter a nipple-sparing prophylactic
mastectomy; silicone cohesive gel implants were placed subcutaneously. Six months
a ter the mastectomy, the implants were exchanged or larger implants, which were
placed subpectorally. One year later (5 months be ore the procedure described
here), the patient had at gra ting to the breast cleavage area and le t axilla.
696

Chapter 42 • Unsatisfactory Shape or Contour

697
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has presented as a small size 34B, with no desire or signi cantly larger
breasts. The position o her breasts has created a large gap between the two im-
plants, without any semblance o normal cleavage. Instead, the implant medial
margins are clearly visible over the sternum. The rippling and areas o signi cant
adhesions are made much worse when the patient bends orward or moves her arm
in one o the many ways that engages the pectoralis muscles.
The patient speci cally asked that we address only her upper chest, because she did
not perceive a problem with the lower breasts and did not want her breasts to be
signi cantly larger.
ANALYSIS O F THE PRO BLEM
The patient is missing so t tissue coverage over the upper chest, and the pectoralis
muscles appear to be contributing to the de ormity by urther de ning the edges o
the implant and accentuating adhesions over the medial breasts and upper poles.
There is little room between the capsule and the skin, but there appears to be
enough to place a thin layer o at in most areas, with thicker depositions planned
or others.
RECOMMENDED SOLUTION TO THE PROBLEM
Bilateral at gra ting to upper and inner breasts
Release o adhesions
TECHNIQ UE
A ter in ltrating the planned areas o harvesting with Ringer’s lactate with epineph-
rine (1:400,000) and lidocaine 0.2% , at was harvested using the Coleman tech-
nique rom the bilateral lovehandles, hips, and outer and inner thighs. A total o
460 ml was harvested, and was re ned down with centri ugation to yield 289.5 ml.
Over the upper breasts onto the sternum, 117 ml was placed into the right breast
and 163 ml into the le t breast using 9 cm type 1 and 3 Coleman cannulas. Exten-
sive release o adhesions was per ormed primarily using the type 3 cannula, with
occasionally use o an 18-gauge needle or persistent adhesions.

Part V-A: Problems in Breast Reconstruction With Prosthetic Devices
698
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient returned 21⁄2 years a ter the one at gra ting procedure, delighted with
her results. The overall appearance o her breasts is more relaxed and natural. Her
sternum and cleavage appear normal with minimal separation o the right and le t
implants and no visible implant edges. The adhesions over the entire superior chest
are signi cantly smoother and minimally perceptible. The overall appearance is o
two normal, natural breasts, and she had no desire or urther enhancement.

Chapter 42 • Unsatisfactory Shape or Contour

699
TEACHING PO INTS
Fat gra ting is the best way to handle many complications o breast implants. By
adding so t tissue coverage over an implant, a surgeon can:

Ô Enhance proportion

Ô Disguise the edges o a breast implant

Ô Make a natural transition into the axilla

Ô So ten the implant

Ô Disguise scars

Ô Release adhesions more predictably
BIBLIO GRAPHY
Cigna E, Ribu o D, Sorvillo V, et al. Secondary lipo lling a ter breast reconstruction with implants.
Eur Rev Med Pharmacol Sci 16:1729-1734, 2012.
Coleman SR, Saboeiro AP. Fat gra ting to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
119:775-785; discussion 786-787, 2007.
Kanchwala SK, Glatt BS, Conant EF, Bucky LP. Autologous at gra ting to the reconstructed breast:
the management o acquired contour de ormities. Plast Reconstr Surg 124:409-418, 209.
Kling RE, Mehrara BJ, Pusic AL, et al. Trends in autologous at gra ting to the breast: a national sur-
vey o the American Society o Plastic Surgeons. Plast Reconstr Surg 132:35-46, 2013.
Losken A, Pinell XA, Sikoro K, et al. Autologous at gra ting in secondary breast reconstruction. Ann
Plast Surg 66:518-522, 2011.
Missana MC, Laurent I, Barreau L, et al. Autologous at trans er in reconstructive breast surgery: in-
dications, technique and results. Eur J Surg Oncol 33:685-690, 2007.
Pérez-Cano R, Vranckx JJ, Lasso JM, Calabrese C, Merck B, Milstein AM, Sassoon E, Delay E, Weiler-
Mitho EM. Prospective trial o adipose-derived regenerative cell (ADRC)-enriched at gra ting
or partial mastectomy de ects: the RESTORE-2 trial. Eur J Surg Oncol 38:382-389, 2012.
Salgarello M, Visconti G, Barone-Adesi L. Fat gra ting and breast reconstruction with implant: an-
other option or irradiated breast cancer patients. Plast Reconstr Surg 129:317-329, 2012.
Seth AK, Hirsch EM, Kim JY, et al. Long-term outcomes ollowing at gra ting in prosthetic breast re-
construction: a comparative analysis. Plast Reconstr Surg 130:984-990, 2012.
Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour de ormities in the reconstructed
breast. Plast Reconstr Surg 116:1300-1305, 2005.

(Trang không có chữ)

Problems in Breast
Reconstruction With
Autologous Tissue
Pa r t V-B

The advent o techniques or autologous breast reconstruction a ter mastectomy and lumpec-
tomy gave plastic surgeons and their patients many more options or success ul breast recon-
struction. Advances in ree tissue trans er made reconstruction possible in patients in whom it
previously was unattainable. Autologous reconstruction has urther enabled plastic surgeons to
create natural-appearing, normal- eeling breasts that maintain a stable appearance over time.
The techniques available or autologous breast reconstruction have become increasingly sophis-
ticated, and the surgeons per orming these procedures have become ever more skill ul. This has
resulted in decreased donor site morbidity, more reliable tissue trans er, and improved aesthetic
results. However, autologous reconstruction a ter mastectomy or lumpectomy still remains a
daunting task. This is a challenging group o patients, all o whom have undergone extensive
ablative surgery and many o whom have received radiotherapy. In this complex group o pa-
tients, there is a signi cant risk o complications and imper ect aesthetic results. The majority o
problems arise rom circulatory compromise o trans erred tissues and mani est as f ap necrosis,
insu cient volume, unsatis actory shape, and poor scarring. The talented and experienced con-
tributors to this section provide innovative, custom-tailored solutions to some o the challenges
that arise when con ronting complications or suboptimal outcomes a ter autologous reconstruc-
tion. With care ul preoperative planning and meticulous execution, even signi cant de ormities
a ter autologous reconstruction can be greatly improved.

Se c t io n o n e
Postoperative Complications
Chapter 43 Ischemic and Necrotic Tissue
43a Salvage With Tissue Expansion Combined With a Bipedicled DIEP Flap
43b Correction With a Latissimus Dorsi Flap A ter TRAM Flap Reconstruction
Chapter 44 Failed Tissue Transfer After Autologous Breast Reconstruction
44a Revising Autologous Breast Reconstruction With a DIEP Free Tissue Trans er
44b Revising Autologous Breast Reconstruction With an SGAP Free Tissue Trans er
703

(Trang không có chữ)

43a Salvage With Tissue Expansion Combined
With a Bipedicled DIEP Flap
St ev en J. Kr o n o w it z , Keit h M. Bl ec h ma n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 35-year-old patient was a nonsmoker and a BRCA-1 carrier. She had no other
signi cant past medical or surgical history. She underwent bilateral prophylactic
nipple-sparing mastectomies using a lateral incision. Be ore surgery her bra size was
34D, and she had bilateral grade 2 ptosis.
Immediate subpectoral placement o 600 cc silicone implants with ADM slings
was per ormed. Six days postoperatively, approximately 50% o her right breast
skin had a violet color, including the NAC, and was surrounded by hyperemia. The
drain e f uent was serosanguineous, and the patient was a ebrile. She was given oral
antibiotics and ollowed closely as an outpatient.
705
Master Page: Ba-Ch Begin_Case A
c h a Pt e r 4 3
ISCHEMIC AND NECROTIC TISSUE
705
705

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
706
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
By postoperative day 12, the nipple is completely necrotic. A large patch o nonvi-
able anteromedial skin, including most o the areola, is demarcated. Neither the
implant nor the ADM is exposed, and no signs o in ection are evident. Her contra-
lateral breast skin, including the NAC, is completely viable.
ANALYSIS O F THE PRO BLEM
Based on its reportable sa ety, nipple-sparing mastectomy has gained popularity or
both prophylactic and therapeutic indications, although clearly de ned risk actors
or complications have yet to be established. Desquamation and necrosis rates can
approach 20% ; however, only a raction o these patients will require surgical de-
bridement. In this patient, the ischemic insult to her mastectomy f ap on the right
side progressed to the point o necessitating skin excision.
Un ortunately, the NAC was nonsalvageable. The a ected sur ace area was large,
and the reduced skin envelope a ter excision would no longer accommodate her
implant volume. There ore the device needed to be removed. Salvage reconstruc-
tion with an autologous f ap will be di cult because o her thin body habitus
(BMI 22) and paucity o so t tissue overlying her abdominal wall. The tissue will
be expanded to extend the skin envelope as much as possible be ore autologous
reconstruction.
RECOMMENDED SOLUTION TO THE PROBLEM
Excision o the NAC and nonviable skin
Removal o the implants
Delayed placement o a tissue expander
Autologous reconstruction a ter maximal expansion

Chapter 43 • Ischemic and Necrotic Tissue

707
TECHNIQ UE
All nonviable skin was excised, and the implant and ADM were removed. The
wound was then curetted and closed primarily in layers. A tissue expander was
placed 3 months later. The breast was expanded serially to a volume o 550 cc.
Nine months a ter the initial excision o necrotic mastectomy f ap skin, the patient
underwent reconstruction using a bipedicled DIEP f ap to maximize ree tissue
trans er with reliable per usion. A ter tissue expander removal and a capsulotomy,
two anastomoses to the internal mammary artery and vein were completed in an
anterograde and retrograde con guration.
Her postoperative course was unremarkable. Six months later, she had nipple and
areola reconstruction, bilateral small-volume autologous at gra ting, and donor
site scar revision.

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
708
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Fourteen months postoperatively, asymmetry is evident; however, the patient has
relatively equivalent volume and ptosis. Good symmetry can be very challenging to
achieve a ter extensive skin loss unilaterally, particularly when the skin envelope o
the contralateral breast is completely preserved. Revision o a nipple-sparing mas-
tectomy to match a contralateral reconstruction is also very di cult, namely be-
cause o a limited ability to maintain implant coverage.
TEACHING PO INTS
Mastectomy f ap necrosis is a dreaded complication a ter a nipple-sparing mastec-
tomy. A variety o risk actors exist, including smoking or aggressive mastectomy
techniques that result in thin, poorly per used f aps. A ter all nonviable skin is de-
brided, the key actor to consider or reconstruction in these patients is skin re-
quirements. Tissue expansion can be used to re-create as much o a skin envelope
as possible, except in patients who have had radiotherapy. This approach is not
recommended in these patients because o the risk o complications. In this patient,
autologous tissue trans er was necessary to provide additional skin a ter expansion.
However, the shortage o subcutaneous abdominal tissue prompted the use o a bi-
pedicled ree f ap to allow the greatest volume to be reliably trans erred.
BIBLIO GRAPHY
Agarwal JP, Gottlieb LJ. Double pedicle deep in erior epigastric per orator/muscle-sparing TRAM
f aps or unilateral breast reconstruction. Ann Plast Surg 58:359-363, 2007.
de Alcantara Filho P, Capko D, Barry JM, et al. Nipple-sparing mastectomy or breast cancer and
risk-reducing surgery: the Memorial Sloan-Kettering Cancer Center experience. Ann Surg Oncol
18:3117-3122, 2011.
Rusby JE, Smith BL, Gui GP. Nipple-sparing mastectomy. Br J Surg 97:305-316, 2010.

43b Correction With a Latissimus Dorsi Flap
After TRAM Flap Reconstruction
Gl y n Jo n es
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 60-year-old woman with le t breast cancer had breast-conserving surgery
with radiotherapy 10 years ago. She developed local recurrence 5 years later that
required a le t mastectomy and axillary clearance; this was per ormed at another
institution. She had immediate reconstruction with a le t unipedicled TRAM f ap
incorporating the irradiated vascular pedicle. Her postoperative course was compli-
cated by skin and at necrosis, which healed spontaneously over a 3-month period.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a shrunken le t breast mound with deep tethering at the site o ne-
crosis, at the 2 o’clock position. As healing occurred over a period o months, the
breast mound shrank urther and deviated toward the axilla. Despite these compli-
cations, a nipple reconstruction was per ormed. This has resulted in an even more
bizarre appearance. The patient now presents or possible revision o her recon-
struction to improve the appearance o her breast.
709

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
710
ANALYSIS O F THE PRO BLEM
The de ormity required both volume augmentation and additional skin sur ace
area. Her distorted nipple reconstruction needed to be corrected.
RECOMMENDED SOLUTION TO THE PROBLEM
Correction o the de ect caused by skin and at necrosis
Volume augmentation
Addition o skin sur ace to replace the missing area
Removal o the poor-quality nipple reconstruction and revision o her nipple-
areolar reconstruction
TECHNIQ UE
The de ect was opened, and the lower pole o the preexisting TRAM f ap was al-
lowed to descend to its correct position with release o extensive scarring supero-
laterally. This created a large skin and at de cit in the upper lateral aspect o the
breast, equivalent to the volume and sur ace area lost by skin and at necrosis. The
patient underwent le t latissimus dorsi myocutaneous f ap reconstruction o the
de ect. The f ap’s muscle and at volume replaced the volume loss incurred by prior
necrosis. The large skin island was used to resur ace the newly created skin wound
that resulted rom reopening o the de ect and resection o her initial nipple recon-
struction. The revised breast mound had satis actory shape, size, and consistency.
A ter complete healing, a new nipple reconstruction was per ormed using a C-V
f ap technique, ollowed by areolar tattooing.
Scoring to
release scar
tissue
Skin and scar
tissue excised
C-V nipple
reconstruction
with tattooing
Latissimus flap
reconstruction

Chapter 43 • Ischemic and Necrotic Tissue

711
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown 1 year a ter reconstruction. All o her goals have been
achieved, and she has a satis actory outcome. Volume is success ully restored using
the muscle and subcutaneous at component o the latissimus f ap. The skin de cit
incurred by previous necrosis has been corrected with the insertion o the latissimus
skin island to resur ace the area.

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
712
TEACHING PO INTS
Correction o a complex de ect such as this requires an understanding o the aes-
thetics o the problem, together with an appreciation o the quality o the tissues.
The irradiated native breast skin retains its tendency to contract over time and
limits the potential or the development o ptosis. Restoration o ptosis requires a
complete re-creation o the original de ect caused by TRAM f ap necrosis and sub-
sequent wound contraction during healing, thereby allowing the lower pole o the
breast to descend in eromedially to a more natural position. It also requires resec-
tion o the previous nipple reconstruction. Once the so t tissue de cit has been re-
created by a drastic so t tissue release, it can be back lled by the insertion o the
latissimus f ap, which provides volume, contour ll, and skin sur ace area.
Important points in this patient’s reconstruction are the ollowing:

Ô Complete so t tissue release is essential to achieve symmetry.

Ô The f ap should be sutured to the margins o the de ect to ensure adequate
ll o volume de cits.

Ô A poorly positioned nipple reconstruction should be resected and appropri-
ately repositioned.
BIBLIO GRAPHY
Andree C, Langer S, Seidenstuecker K, et al. A single center prospective study o bilateral breast recon-
struction with ree abdominal f aps: a critical analyses o 144 patients. Med Sci Monit 19:467-
474, 2013.
Dobbs NB, Lati HR. Di use FDG uptake due to at necrosis ollowing transverse rectus abdominus
myocutaneous (TRAM) f ap reconstruction. Clin Nucl Med 38:652-654, 2013.
Mohan AT, Al-Ajam Y, Mosahebi A. Trends in tertiary breast reconstruction: literature review and
single centre experience. Breast 22:173-178, 2013.
Newman MI, Samson MC, Tamburrino JF, et al. An investigation o the application o laser-assisted
indocyanine green f uorescent dye angiography in pedicle transverse rectus abdominus myocuta-
neous breast reconstruction. Can J Plast Surg 19:e1-e5, 2011.

44a Revising Autologous Breast Reconstruction
With a DIEP Free Tissue Transfer
Mo u st a ph a Ha md i
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 43-year-old patient had previously undergone a modi ed radical mastectomy
and then radiotherapy on the right side 2 years previously. She had delayed breast
reconstruction with a pedicle latissimus dorsi myocutaneous f ap and a silicone gel
implant. A nipple reconstruction and subsequent tattooing were also per ormed.
The patient was re erred to my clinic to enhance the reconstruction.
c H a Pt e r 4 4
FAILED TISSUE TRANSFER
AFTER AUTOLOGOUS BREAST
RECONSTRUCTION
713

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
714
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient complains about breast symmetry and twitching o the latissimus dorsi
muscle when she moves her right arm. Clinical examination shows that the breasts
are asymmetrical in shape and volume and that the IMF on the right side is higher
than that on the le t. The reconstructed nipple has lost projection. Baker grade II
capsular contracture is noted. The mastectomy scar is high on the chest wall and
very prominent.
ANALYSIS O F THE PRO BLEM
When a local pedicle f ap is no longer available, the lower abdominal wall can pro-
vide enough tissue to replace the implant volume and to achieve better breast sym-
metry. There ore a ree deep in erior epigastric per orator (DIEP) f ap was planned
to replace the implant and increase the missing breast volume to achieve breast
symmetry. Preoperative per orator mapping is essential in this technique to shorten
the operative time and decrease postoperative complications. We used a CT angio-
gram to localize the best per orator and to study the intramuscular course o the
vessels.

Chapter 44 • Failed Tissue Transfer After Autologous Breast Reconstruction

715
RECOMMENDED SOLUTION TO THE PROBLEM
When a ree f ap is used to salvage a pedicle latissimus dorsi with implant breast re-
construction, the ollowing actions should be per ormed:
Preparation o the new pocket or the ree f ap under the upper breast skin
Raising the pectoralis major muscle/breast skin f ap en bloc to reduce the
risk o skin necrosis i the upper breast skin is severely damaged or replaced
by the new f ap
Discarding the previously reconstructed nipple i the new f ap will result in a
di erent level o the nipple
Deepithelializing the latissimus dorsi skin f ap i there is additional bulk
and/or cut the thoracodorsal nerve to relieve muscle twitching
Fixing the pectoralis major muscle back on the thoracic wall
Splitting the pectoralis major muscle at the level o third or ourth intercos-
tal space to prepare the internal mammary vessels
Harvesting the DIEP f ap
Avoiding a patchwork result by insetting the ree f ap into the IMF
Consideration o additional correction, such as at gra ting and/or scar cor-
rection, 3 to 6 months later
TECHNIQ UE
The prosthesis was removed along with the whole capsule and all adjacent scar tis-
sue, especially in the region o the anterior axillary old. The upper breast skin was
undermined to the superior border o the breast ootprint. The pectoralis muscle
was repositioned into its original position. The skin o the latissimus dorsi was
deepithelialized and used or additional autogenous bulk. However, the muscular
part in the axilla was excised and the motor nerve sectioned, sparing the vascular
pedicle, to prevent muscle twitching and excess bulk under the arm.

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
716
A DIEP f ap was harvested and the vessels anastomosed to the internal mammary
vessels. The postoperative course was unevent ul. Surgical correction o the mastec-
tomy scar, with at gra ting at the upper breast area, was per ormed on both sides
4 months a ter the surgery.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The nal results are shown at 1-year ollow-up. In the case o an unsatis actory
breast reconstruction, a tertiary reconstruction is o ten indicated, either to improve
the aesthetic result and patient com ort or to salvage the procedure a ter a total
ailure o the implant reconstruction.

Chapter 44 • Failed Tissue Transfer After Autologous Breast Reconstruction

717
In our experience, the most common indications or tertiary reconstruction are: dis-
satis action with the aesthetic result, in ection with or without implant exposure,
and capsular contracture, which occur in 45% , 26% , and 24% o the cases, respec-
tively. The high number o our patients who requested a better aesthetic outcome
may ref ect changes in the breast cancer/reconstruction population during the last
decade. In our practice, younger patients consult with us to improve the outcome
o implant-breast reconstruction, and we have noticed that their aesthetic demands
have continuously increased.
In unilateral cases, the contralateral breast should be considered in the surgical plan
since the best available tissue will be used to salvage the ailed reconstructed breast.
Any indication or prophylactic mastectomy must be discussed; i indicated, a bilat-
eral breast reconstruction can then be per ormed.

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
718
Breast reconstruction techniques have improved greatly in recent decades; autolo-
gous breast reconstruction is now the gold standard, because it provides women
with a very natural-appearing breast. Patient’s demands and expectations have
changed accordingly. Consequently, these reconstructive procedures are now judged
with the same attention to detail as aesthetic procedures.
TEACHING PO INTS
When the decision is made to use a ree abdominal f ap to salvage a latissimus
dorsi/implant breast reconstruction, care ul evaluation o the contralateral breast is
essential. The risk o developing cancer in the contralateral breast should be consid-
ered be ore choosing the best reconstructive option or salvage o a unilateral re-
construction.
When di erent tissue is inserted in the middle o previously irradiated skin, the
DIEP ree f ap is typically placed into the IMF, thus reducing the patch e ect. When
nipple reconstruction is per ormed, it is important to judge the anticipated postop-
erative nipple position to decide where to open the breast. In this patient, it might
have been better to discard the previously reconstructed right nipple because o its
lack o projection and asymmetrical position compared to the le t side. The purpose
o the salvage procedure is to create a symmetrical ootprint when compared with
the contralateral breast. However, urther correction might still be necessary 3 to 6
months later to achieve better symmetry.
BIBLIO GRAPHY
Agaoglu G, Erol OO. Delayed breast reconstruction with latissimus dorsi f ap. Aesthetic Plast Surg
33:413-420, 2009.
Hamdi M, Hijjawi J. Breast reconstruction per orator f aps. In Nahabedian MY, ed. Cosmetic and Re-
constructive Breast Surgery. Philadelphia: Saunders-Elsevier, 2009.
Hammond DC. Latissimus dorsi f ap breast reconstruction. Clin Plast Surg 34:75-82, 2007.
Mathes SJ, Alkureishi LW. Secondary breast reconstruction. In Mathes SJ, ed. Plastic Surgery. Philadel-
phia: Saunders-Elsevier, 2006.
Spear SL, Boehmler JH, Taylor NS, et al. The role o the latissimus dorsi f ap in reconstruction o the
irradiated breast. Plast Reconstr Surg 119:1-9, 2007.
Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour de ormities in the reconstructed
breast. Plast Reconstr Surg 116:1300-1305, 2005.

44b Revising Autologous Breast Reconstruction
With an SGAP Free Tissue Transfer
Mo u st a ph a Ha md i
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 45-year-old patient had undergone immediate breast reconstruction with an
expander/implant procedure. There was no postoperative radiotherapy, but the re-
sult was complicated by capsular contracture and the implant had to be removed.
The patient was re erred to our clinic or autologous breast reconstruction. Because
o the lack o abdominal tissue, a superior gluteal artery per orator (SGAP) recon-
struction was per ormed. The surgery was unevent ul, but the f ap ailed on the th
day a ter surgery because o venous thrombosis; the SGAP was removed. A later
hematologic examination con rmed lupus anticoagulant (1 ) syndrome. The patient
re used an implant or latissimus dorsi f ap breast reconstruction because o her his-
tory o rheumatoid arthritis and the previous implant ailure. There ore we planned
a tertiary SGAP f ap, harvested rom the contralateral buttock, in concert with anti-
thrombotic therapy.
719

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
720
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
With the ailure o the ree SGAP breast reconstruction, the patient has gone back
to a level “zero.” However, the best donor site and the recipient vessels have already
been used. Clinical examination reveals that the postmastectomy scar is positioned
high on the chest. The skin is o good color and quality. The right breast is mildly
ptotic.
ANALYSIS O F THE PRO BLEM
The ailure o a ree f ap breast reconstruction is a very stress ul and demanding
situation, not only or the surgeon but what is most important, or the patient and
her amily, who have already overcome the challenges o the initial tumor and then
the ailure o a major reconstructive operation.Among the available ree f aps, the
contralateral SGAP and the transverse myocutaneous gracilis (TMG) f ap are our
top choices a ter a ailed SGAP; the choice depends on the tissue redundancy and
the patient’s donor site pre erence. It is more logical or us to choose the contralat-
eral SGAP as a donor site to achieve a symmetrical buttock. However, harvesting a
contralateral SGAP ree f ap necessitates changing the patient’s position twice dur-
ing surgery. An additional technical problem is the recipient vessels, because the in-
ternal mammary vessels were already used.