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

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
722
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The nal results are shown at 2-year ollow-up. The patient had a supple autolo-
gous breast reconstruction with nice symmetry.
The donor site has healed very well.

Chapter 44 • Failed Tissue Transfer After Autologous Breast Reconstruction

723
TEACHING PO INTS
Salvage o a ailed autologous breast reconstruction is a complex and challenging
task. A sensitive psychosocial approach to the patient and amily is critical. Be ore
considering a second ree f ap, extensive preoperative investigations should be un-
dertaken to nd out the reasons or the previous ailure. In our patient, postopera-
tive tests revealed the presence o lupus anticoagulant, which is one o the immu-
noglobulins responsible or antiphospholipid syndrome. Lupus anticoagulant is
ound in only 1% o the population and can o ten be detected in patients with deep
venous thrombosis. Un ortunately, no routine, inexpensive blood tests can predict
such a hypercoagulability disorder. Although hypercoagulable conditions are rare,
any unusual amily history or previous pregnancy-related complications should be
an indication that more detailed preoperative clotting studies are necessary. A late
pedicle thrombosis (as in this case on the th day a ter surgery) is also one o the
indicators or an underlying pathology, prompting an evaluation. Although a coag-
ulopathy is not an absolute contraindication or tertiary breast reconstruction with
autologous ree tissue, we re use to per orm a second ree f ap in patients who are
unable to quit smoking.
Un ortunately, donor sites are scarce in these patients. I the anterior abdominal
wall was already used, secondary options such as the SGAP or TMG f aps should
be considered. When used alone or combined with an implant, the latissimus dorsi
or thoracodorsal artery per orator (TDAP) f aps represent another sa e and reliable
alternative in these challenging cases, because they are relatively simple procedures.
When a second ree f ap is planned, the choice o recipient vessels should always be
the rst consideration. The internal mammary vessels are our rst choice as recipi-
ent vessels or ree f ap breast reconstruction. When the internal mammary vessels
are used or a previous microanastomosis, a color duplex examination is usually
adequate to reevaluate the availability, location, and diameter o the internal mam-
mary vessel stumps. Preparing the vessels at a higher intercostal space is the ideal
approach; however, these vessels have o ten been used already at a high level, and
the vessel stump may be too short or otherwise unsuitable or the anastomosis.
Vein gra ts are usually used to bridge the gap; yet a vein gra t can collapse easily
when it is used to bridge two venous vessels in per orator f aps.
Based on our clinical experience, the venous return in a per orator f ap is reduced
compared with a muscle-skin f ap. There ore we pre er to use an arterial gra t or
this purpose. Our rst choice or an artery gra t is the deep in erior epigastric per-
orator (DIEP). When both arteries are used, or example, with bilateral DIEP f aps,
or i the patient does not want to have the abdominal wall opened to harvest the
gra t, the thoracodorsal artery is a good alternative.
Continued

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
724
However, we never use the ipsilateral thoracodorsal artery as a gra t. It is manda-
tory to keep the pedicle o the latissimus dorsi f ap intact in case another salvage
f ap is needed in the uture. For the same reason, we do not like to use the thora-
codorsal vessels as recipient vessels or ree f ap breast reconstruction; in particular,
we pre er not to use them or tertiary breast reconstruction. I necessary, the micro-
anastomosis can be per ormed with the serratus branch but not with the main ped-
icle. When all o the previously mentioned vessels have been used, alternatives are
the distal stump o the internal mammary artery, contralateral internal mammary
vessels, intercostal vessels, or any internal mammary or internal carotid artery per-
orator.
Tertiary surgery a ter autologous breast reconstruction ailure presents limited op-
tions, and additional reoperations are requently indicated.
Care ul analysis o a patient’s history must be per ormed, because it may indicate
the condition o hypercoagulation. Blood and coagulation tests, including lupus
anticoagulant, cardiolipin, actor VIII, antiphospholipid, protein S, protein C, and
antithrombin and APC resistance, are essential in every case o ree f ap ailure.
An implant with or without a latissimus dorsi f ap is our rst choice a ter a ree
f ap breast reconstruction has ailed. When a second ree f ap is indicated in breast
reconstruction, an acceptable recipient vessel should be investigated rst. The tho-
racodorsal vessels should never be used as recipient vessels or the second ree f ap.
These vessels should always be preserved; the latissimus dorsi f ap should be con-
sidered as a li eboat procedure. Only an experienced surgeon should per orm a sec-
ond ree f ap in breast reconstruction.
BIBLIO GRAPHY
Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood f ow in ree transverse rec-
tus abdominis myocutaneous and deep in erior epigastric per orator f aps. Plast Reconstr Surg
106:1295-1299, 2000.
Davison SP, Kessler C, Al-Attar A. Microvascular ree f ap ailure caused by unrecognized hypercoagu-
lability. Plast Reconstr Surg 124:490-495, 2009.
Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing recipient vessels or per o-
rator ree f ap in breast reconstruction: the role o the internal mammary per orators. Br J Plast
Surg 57:258-265, 2004.
Kompatscher P, Manestar M, Schuster A, et al. The thoracoacromial vessels as recipient vessels in
microsurgery and supermicrosurgery: an anatomical and sonographic study. Plast Reconstr Surg
115:77-83, 2005.
Levine JS, Branch DW, Rauch J. The antiphospholipid syndrome. N Engl J Med 346:752-763, 2002.
Mehrara BJ, Santoro TD, Arcilla E, et al. Complications a ter microvascular breast reconstruction: ex-
perience with 1195 f aps. Plast Reconstr Surg 118:1100-1109, 2006.

SEC T IO N T WO
Suboptimal Aesthetic Outcomes
Chapter 45 Persistent Volume De iciencies
45a Salvage With Fat Grafting, Implant Insertion, and a TRAM Flap
45b Tissue Expansion With TRAM Flap Repositioning and Implant Insertion
Suboptimal Aesthetic Outcomes
725

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45a Salvage With Fat Grafting, Implant Insertion,
and a TRAM Flap
Ma u r ic e Y . Na h a bed ia n
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 45-year-old woman with stage II right breast cancer had a unilateral mastec-
tomy and immediate reconstruction with a pedicle TRAM ap at an outside insti-
tution. Immediately a ter the operation, she reported that her volume and contour
symmetry were good. She required postoperative radiotherapy to the reconstructed
breast. Two years later, she presented with breast asymmetry. She denied secondary
operations on both breasts. She was pleased with the contour o both breasts; how-
ever, she thought that the irradiated right breast was now smaller than the natural
le t breast. She was in a general state o good health and did not use tobacco.
C h a PT Er 4 5
PERSISTENT VOLUME
DEFICIENCIES
727

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
728
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On physical examination, the patient has a noticeable volume discrepancy. The ir-
radiated right breast is noticeably smaller. The quality o her skin and subcutaneous
tissues is so t and supple. She has no evidence o at necrosis, and all incisions are
well healed. Radiation damage is not extensive. The level o the IMF is the same on
both sides.
ANALYSIS O F THE PRO BLEM
The observation that postoperative radiation to an autologous reconstruction can
result in ap shrinkage over time has been previously described. This is most likely
the result o damage to the microcirculation, causing gradual at atrophy. Whether
a pedicle or per orator ap is used or reconstruction does not matter, because both
can be a ected by the radiotherapy. The patient’s irradiated tissues did not appear
to be severely damaged. However, secondary operations on these tissues can be
problematic and result in in ection, delayed healing, at necrosis, and incisional de-
hiscence. Options or correction included ipsilateral or contralateral procedures.
RECOMMENDED SOLUTION TO THE PROBLEM
Autologous at gra ting to the irradiated ap (f rst choice)
Contralateral reduction mammaplasty or mastopexy (second choice)
Placement o a small implant under the irradiated ap (third choice)
TECHNIQ UE
The decision was made to proceed with autologous at gra ting. The donor sites
or at harvest were the ank and hip areas bilaterally. The areas were inf ltrated
with a standard tumescent solution containing epinephrine and lidocaine. Twenty
minutes later, at was harvested using a 60 cc syringe and a 3 cc cannula. The uid
raction o the harvested at was discarded, and the at was placed on Tel a pads to
drain away additional uid, oils, and debris. Another option is to wash the at with
a bu ered solution. The prepared at was placed in 20 cc syringes and then inf l-
trated into the subcutaneous compartment and into the ap using a 2 mm bucket
handle–tip cannula. A total o three at gra ting sessions was required. The volumes
inf ltrated were 125 cc, 150 cc, and 145 cc, respectively. A ter the second session o
at gra ting, she had an area o at necrosis on her lateral breast. This was excised
during the third session.

Chapter 45 • Persistent Volume Deficiencies

729
The at gra ting resulted in improved volume immediately a ter each session; how-
ever, the results were temporary and minimally success ul. To treat the persistent
asymmetry, a small reduction mammaplasty-mastopexy was per ormed on her con-
tralateral breast. Fi ty grams o tissue was removed through a Wise pattern.
This operation improved the contour o her le t breast; however, volume asymme-
try persisted. A small saline implant was placed under the TRAM ap on the right
to achieve the desired volume and symmetry. The in erior ap incision was opened
to a length o 5 cm. The plane between the ap and the pectoralis major muscle
was identif ed and entered. A space was created to accommodate the implant. A
150 cc Moderate Prof le saline implant (Mentor, Santa Barbara, CA) was selected,
inserted, and f lled to 175 cc. The pocket was irrigated with an antibiotic solution,
hemostasis was achieved, and the incision was closed. A drain was not needed.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The preoperative photograph demonstrates the patient’s volume asymmetry, which
persisted a ter three sessions o autologous at gra ting. A contralateral reduction
mammaplasty and insertion o an ipsilateral saline implant provided volume sym-
metry. The patient is pleased with the outcome.

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
730
TEACHING PO INTS
Fat gra ting is o tentimes very success ul in correcting contour de ormities a ter
autologous or prosthetic reconstruction. In nonirradiated breasts, results are usu-
ally predictable and satis actory; however, in irradiated breasts, the results are less
predictable in my experience. In addition, irradiated tissues usually require more
at gra ting sessions to obtain the desired outcome. In this patient, despite the in-
f ltration o 420 cc o at over three sessions, minimal change was noted. This was
probably the result o either poor quality at; clumping o the at, which prevented
revascularization; or poor vascularity at the recipient site. It is important not to
overf ll the target sites with gra ted at, because this will more likely than not result
in at resorption or oil cyst ormation. In either case, the result was insu f cient vol-
ume correction. The area o secondary at necrosis was probably the result o tissue
trauma during the at gra ting sessions or nonvascularized at gra t.
Reduction mammaplasty and mastopexy techniques are usually very e ective in
achieving symmetry. It is important to limit the amount o parenchymal excision.
Excess tissue removal can cause the reverse problem. I pre er to use a Wise pattern
in these cases to prevent the creation o an overprojecting breast, which is usually
seen with vertical scar techniques. Sometimes a mastopexy alone is su f cient.
Placement o a small saline implant is another e ective method o volume enhance-
ment. It can be trickier in a previously irradiated breast. In these patients, I always
use a saline implant, because it is easier to insert. I always place it on top o the pec-
toralis major muscle. The irradiated pectoralis major is relatively sti , less compli-
ant, and more o ten results in unusual contours when an implant is under it. For
this reason, larger devices are not recommended. I usually do not place pref lled
silicone gel devices, because the tissues are relatively sti and implant insertion is
more traumatic and di f cult. In irradiated tissues, capsular contracture is always a
concern. Incisional dehiscence can occur because o the added pressures and irra-
diated skin. Multilayer closure is the rule, and placement o some interrupted skin
sutures is use ul.
BIBLIO GRAPHY
Losken A, Pinell XA, Sikoro K, et al. Autologous at gra ting in secondary breast reconstruction. Ann
Plast Surg 66:518-522, 2011.
Rigotti G, Marchi A, Galiè M, et al. Clinical treatment o radiotherapy tissue damage by lipoaspirate
transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg
119:1409-1422, 2007.
Rogers NE, Allen RJ. Radiation e ects on breast reconstruction with the deep in erior epigastric per-
orator ap. Plast Reconstr Surg 109:1919-1924, 2002.
Spear SL, Wol e AJ. The coincidence o TRAM aps and prostheses in the setting o breast reconstruc-
tion. Plast Reconstr Surg 110:478-486, 2002.

45b Tissue Expansion With TRAM Flap Repositioning
and Implant Insertion
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 42-year-old woman previously had immediate breast reconstruction with bi-
lateral TRAM aps. She also had secondary bilateral NAC reconstruction. At pre-
sentation she was dissatisf ed with both the shape and contour o her result. She
had di f culty wearing a bra and some o her clothing because o the contour o the
IMF area on both sides. Signif cant past medical history included a healed median
sternotomy incision or cardiac surgery.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient’s primary problem pertains to her TRAM aps. They were inserted in a
segmental manner along the IMF without re-creation o either the medial or lateral
aspect o the old. This de ormity is visible on rontal and oblique views. Each ap
has created an isolated central segment on her breast mounds. The lower pole o
each ap has descended in eriorly. She also had implants inserted to correct the vol-
ume def ciency rom the original TRAM aps. This has resulted in a very unnatural
contour and exaggeration o the abnormal ap location.
731

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
732
ANALYSIS O F THE PRO BLEM
When autologous tissue is used to re-create a breast mound, it is important to con-
sider aesthetic units. Similar to aesthetic units in the ace, the same concept applies
to the breast. Whenever a ap is inserted to produce an IMF, it is necessary to cre-
ate the entire old. This case demonstrated what happens when only a segment was
reproduced, resulting in an unacceptable aesthetic result and a distorted mound.
Insertion o implants only exaggerated the de ormity.
This patient had a very unusual problem, and two major areas needed alteration:
correction o the ap position, which also extends the IMF, and volume def ciency.
Volume can be enhanced either with implants or expanders. The additional benef t
o expanders is that they increase the size o the original TRAM aps to allow im-
proved repositioning.
RECOMMENDED SOLUTION TO THE PROBLEM
Repositioning and insetting o the original aps along the original IMFs
Insertion o tissue expanders
TECHNIQ UE
This patient’s correction required a two-step operation. The f rst step consisted o
insertion o tissue expanders under the TRAM aps in eriorly, and under the pecto-
ralis muscle superiorly.
Tram flap skin island
Expander placement

Chapter 45 • Persistent Volume Deficiencies

733
The entire breast mounds were then expanded over several months to create redun-
dant tissue. In the second step approximately 4 months later, the expander was re-
moved, the original TRAM aps mobilized and advanced, and permanent implants
inserted.
The TRAM aps were remobilized and advanced to a more natural location, and
IMFs were re-created.
After expansion and implant placement

Part V-B: Problems in Breast Reconstruction With Autologous Tissue
734
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Postoperatively the contour and shape o the pa-
tient’s reconstructed mounds are signif cantly im-
proved. Her TRAM aps are better aligned along
the medial IMFs, and the placement o implants has
provided adequate volume. This is a reasonable im-
provement but by no means an outstanding result
because o the limitations placed by the original
surgery.

Chapter 45 • Persistent Volume Deficiencies

735
TEACHING PO INTS
This patient’s problem was complex. The solution required creation o continu-
ous IMFs by repositioning the original TRAM aps. Tissue expansion was needed
to enlarge the original aps. Readvancement o the aps superiorly improved the
overall contour o her breast mounds.
BIBLIO GRAPHY
Kajikawa A, Ueda K, Tateshita T, et al. Breast reconstruction using tissue expander and TRAM ap
with vascular enhancement procedures. J Plast Reconstr Aesthet Surg 62:1148-1153, 2009.
Saulis AS, Mustoe TA, Fine NA. A retrospective analysis o patient satis action with immediate post-
mastectomy breast reconstruction: comparison o three common procedures. Plast Reconstr Surg
119:1669-1676; discussion 1677-1678, 2007.
Shaikh-Naidu N, Preminger BA, Rogers K, et al. Determinants o aesthetic satis action ollowing
TRAM and implant breast reconstruction. Ann Plast Surg 52:465-470; discussion 470, 2004.
Tadiparthi S, Alrawi M, Collis N. Two-stage delayed breast reconstruction with an expander and ree
abdominal tissue trans er: outcomes o 65 consecutive cases by a single surgeon. J Plast Reconstr
Aesthet Surg 64:1608-1612, 2011.

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Deformities Associated
With Lumpectomy,
Partial Mastectomies,
and Radiation
Pa r t V-C

One o the major objectives associated with any type o breast reconstruction is the creation
o symmetry. However, asymmetry can occur with autologous or implant reconstruction, and
partial de ects rom lumpectomy and radiation can also result in asymmetry. Another problem
seen in all types o reconstructive procedures is secondary contour de ormities. These can be the
result o many contributing actors. In implant reconstructions with expanders, capsular con-
tracture with the nal implant can lead to both shape irregularities as well as asymmetry. The
incidence o capsular contracture increases signi cantly in the radiated patient. Also, di cultly
with the initial expansion can cause similar problems. With autologous reconstruction, partial
f ap loss can lead to asymmetry or a contour de ormity o the reconstructed breast, and radiation
to autologous tissue can lead to signi cant volume loss over time.
Lumpectomy in appropriately selected patients can lead to excellent results. However, i signi -
cant tissue is resected, both asymmetry and a local de ormity may result. In addition, radiation
treatments can exacerbate these problems due to so t tissue changes, either acute or long term.
Numerous options or revision surgery are available or these patients.
Selecting the best procedure to correct asymmetries and contour de ormities depends on the
original procedure and what reconstructive options are available. Today, at has become an ex-
cellent source o tissue to correct both implant and autologous reconstructions. With implant
reconstruction, at injection can provide so t tissue coverage and correct irregularities not man-
aged by the implant. Fat can also enhance autologous reconstructions to create adequate vol-
ume, especially i the original f ap ailed.
Lumpectomy de ects can be managed with multiple options including at, implants, and autolo-
gous tissue trans er. As the number o patients undergoing lumpectomy and radiation increases,
the problems associated with this procedure are more numerous. W hen new tissue is required,
the latissimus dorsi and TRAM f aps remain the mainstay o autologous options in this group o
patients.
Several cases in which both asymmetry and contour de ormities result a ter lumpectomy and
radiation treatment will be presented, and numerous options will be discussed. Not every per-
mutation is discussed, but the ollowing cases provide a good representation o typical problems
encountered.

Se C t io n
Complications and Suboptimal Aesthetic Outcomes
Chapter 46 Deformities After Lumpectomy, Radiation,
and Breast Reconstruction
46a Fat Gra ting
46b Capsulectomy With Implant Replacement and Contralateral Reduction Mammaplasty
46c Correction o a Lumpectomy De ect With a Latissimus Dorsi Flap and Implant
46d Latissimus Dorsi Flap Reconstruction and Contralateral Mastopexy
46e Combined Latissimus Dorsi Myocutaneous Flap With Implants and Fat Trans er
46 Repair With a Latissimus Dorsi Flap and an Adjustable Implant
46g Revision o TRAM Flap Breast Reconstruction
46h Completion o Previous Lumpectomy and Radiation With Nipple-Sparing Mastectomy
and a Buried TRAM Flap
739

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46a Fat Grafting
emma n u el Del ay
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 38-year-old woman presented with complaints about morphologic alterations
a ter conservative treatment o cancer in her le t breast.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a major de ormity with the absence o the lower outer quadrant o
her le t breast, along with breast asymmetry.
ANALYSIS O F THE PRO BLEM
Although autologous at gra ting has been widely validated or the management
o patients with a total mastectomy, its bene t or the correction o the sequelae o
breast-conserving treatment, speci cally or lumpectomy and radiotherapy, has yet
to be con rmed. A clinical trial addressing this question has just been completed.
741
C h a Pt e r 4 6
DEFORMITIES AFTER
LUMPECTOMY, RADIATION,
AND BREAST RECONSTRUCTION
741

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
742
The spontaneous risk to have a new breast cancer or a recurrence o the primary
tumor is high. Strict control—making sure the patient and the team understand the
necessity o a regular ollow-up—is needed to minimize this risk, which would have
potential medicolegal consequences i the patient were not properly in ormed. The
protocol includes complete breast imaging with mammography, ultrasonography,
and MRI, per ormed by a skilled radiologist. The radiologist must agree with the
patient’s oncologist, who is requently the doctor who re erred the patient or plas-
tic surgery; agreement between the radiologist and the oncologist is also generally
required be ore at gra ting is attempted.
To monitor the outcome, breast imaging by mammography and ultrasonography is
repeated 1 year a ter the at gra ting procedure; i there is any doubt about recur-
rence, a microbiopsy by the radiologist is recommended. Our study has included
100 consecutive patients with sequelae o conservative treatment undergoing at
gra ting and strict imaging ollow-up. In our study, the risk o local recurrence did
not increase but rather slightly decreased; there was only one case o local recur-
rence (1% ) or an expected rate o approximately 6% (the spontaneous risk o
recurrence a ter great conservative treatment is approximately 1% to 1.5% each
year).
The patient presented here was included in the study. She was deemed an excellent
candidate or at gra ting to correct her de ormity a ter breast-conserving surgery.
RECOMMENDED SOLUTION TO THE PROBLEM
Because the de ormation is major, care ul planning is necessary to achieve success-
ul correction o the de ormity. Proper planning includes the ollowing steps:
Two or three sessions o lipomodeling
(I we were to try to obtain this correction in just one session, we could only
obtain a at necrosis lesion; or optimal at gra ting, each “spaghetti strand”
o at must have adequate vascularity surrounding it.)
Partial breast reconstruction with a latissimus dorsi f ap could be considered
(For us, this solution was deemed a second choice, because it would leave
scars. We decided to keep this option in reserve in case the patient has a local
recurrence, in which case this solution would result in a good breast recon-
struction using the latissimus dorsi.)
TECHNIQ UE
Fat gra ting was proposed to correct the de ormity. Two sessions were per ormed
successively, with placement o 171 and 149 cc o re ned at in the breast. For the
rst session, the at was harvested rom the abdomen and the supra-iliac areas.
For the second session, at was harvested rom the thighs. The oil and debris were
then discarded, leaving the puri ed at. The at was centri uged or 20 seconds at
300 rpm. The at was trans erred with special cannulas designed or breast lipo-

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

743
modeling (one 13 cm long and one 20 cm long); i you don’t have this cannula,
you can use Coleman’s cannula. The at was trans erred in the orm o slender,
spaghetti-like cylinders. The lipoaspirate was injected in these ne strands as the
cannula was withdrawn. Good spatial visualization was necessary to orm a three-
dimensional matrix and to avoid atty collections that would lead to at necrosis
because o inadequate contact with a blood supply. A simple greasy dressing is ap-
plied or 10 days. We recommend avoiding pressure on the treated areas (usually
no bra or 15 days).
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Comparison o the le t breast with the right breast 1 year a ter surgery reveals a
signi cant improvement o the postoperative de ormation, notably in the lower
outer quadrant o the breast. The breast now has an aesthetic shape and so tness.
I the patient desires, a third session could be proposed to obtain a nearly per ect
result.
Our ndings illustrate that at gra ting is a major advance or the management o
moderate sequelae with conservative treatment. Fat gra ting makes it possible to
restore the shape and so tness o the breast to an extent never achieved with previ-
ous techniques. With a large experience o breast de ormation correction with the
lipomodeling technique, it is possible to enlarge the indications and to propose this
technique even or the correction o larger de ormation with the approach o mul-
tiple (two or three) sessions.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
744
TEACHING PO INTS
Each microtunnel o gra ted at must be designed to be surrounded by well-
vascularized tissue. Any brous strings and adhesions in the breast can be released
through percutaneous asciotomies by putting the brous bands on tension with
a Gillies hook or a double hook and cutting the brous bands with the tip o a
14-gauge trocar. Fasciotomies must be done with caution: too many asciotomies
increase the risk o at necrosis.
BIBLIO GRAPHY
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, Gounot N, Bouillot A, et al. Autologous latissimus breast reconstruction. A 3-year clinical
experience with 100 patients. Plast Reconstr Surg 102:1461-1478, 1998.
Delay E, Gosset J, Toussoun G, et al. [E cacy o lipomodelling or the management o sequelae o
breast cancer conservative treatment] Ann Chir Plast Esthet 53:153-168, 2008.
Delay E, Gosset J, Toussoun G, et al. [Post-treatment sequelae a ter breast cancer conservative surgery]
Ann Chir Plast Esthet 53:135-152, 2008.
Gosset J, Flageul G, Toussoun G, et al. [Lipomodelling or correction o breast conservative treatment
sequelae. Medicolegal aspects. Expert opinion on ve problematic clinical cases] Ann Chir Plast
Esthet 53:190-198, 2008.
Gosset J, Guerin N, Toussoun G, Delaporte T, Delay E. [Radiological evaluation a ter lipomodel-
ling or correction o breast conservative treatment sequelae] Ann Chir Plast Esthet 53:178-189,
2008.
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.
Mauriac L, Luporsi E, Cutuli B, et al. Summary version o the standards, options, and recommenda-
tions or nonmetastatic breast cancer. Br J Cancer 89(Suppl 1):S17-S31, 2003.

46b Capsulectomy With Implant Replacement
and Contralateral Reduction Mammaplasty
n ea l h a n d el
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 58-year-old Hispanic woman was re erred or treatment o breast de ormity
and asymmetry a ter having a lumpectomy and radiation therapy or carcinoma o
the right breast. She was initially diagnosed with breast cancer at age 41. She stated
that her tumor was “small.” She was treated with lumpectomy alone and did not
receive radiation or chemotherapy. Three years later, she developed a local recur-
rence, and the lump was excised again, a ter which she underwent a ull course o
radiation therapy. A ter the second lumpectomy and radiation, she developed as-
symetry and an obvious de ormity o the right breast. Four years later, she under-
went a “breast reconstruction” in Tijuana, Mexico. The reconstruction consisted o
bilateral insertion o saline implants; she was uncertain o the type, style, and vol-
ume o implants used.
When this patient presented to our clinic, she complained o pain, rmness, and
distortion o her right breast, in addition to asymmetry, because the le t breast was
signi cantly larger and more pendulous than the right breast. Her clothing choices
were very restricted because o her breast asymmetry.
Other than her history o breast cancer, this patient was in good health; her only
previous surgery was a ace li t and chin implant. She has never smoked cigarettes
and has no amily history o breast cancer.
745

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
746
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient is a healthy-appearing, slightly obese woman. Her breasts are signi -
cantly asymmetrical. The right breast is much smaller than the le t breast by ap-
proximately 50% , and it is spherically de ormed, very rm, and slightly tender to
palpation with Baker grade IV capsular contracture. The lateral breast contour has
a noticeable concavity rom so t tissue loss as a result o the two previous lumpec-
tomies; there is also a well-healed, transverse lumpectomy scar with adjacent hyper-
pigmentation o the skin. The so t tissues are indurated in the area o the lumpec-

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

747
tomy. The le t breast is considerably larger and more pendulous, and the implant
appears to be subpectoral. The nipple on the le t breast is 5 cm lower than the IMF,
and points downward as a result o grade 3 ptosis. There are well-healed periareo-
lar scars bilaterally rom the implant insertion. There are no palpable breast masses.
ANALYSIS O F THE PRO BLEM
This patient has several o the common de ormities that may occur a ter breast
conservation therapy. The right breast is smaller in volume rom the two lumpec-
tomies and radiation-induced contraction. In addition, the area at the lumpectomy
site is depressed, there are radiation-induced pigmentary skin changes, and she has
signi cant capsular contracture, which is common when an implant is placed in
an irradiated eld. She has signi cant asymmetry, and the contralateral breast is
pendulous.
A number o approaches were possible in this case. Clearly, the most direct way to
achieve symmetry would be to reduce and upli t the le t breast. This patient was
relatively satis ed with the volume o her right breast, and eager to undergo le t
breast reduction. She also wished to have her saline implants replaced with silicone
gel devices. There ore we recommended implant removal and replacement on the
le t side, in conjunction with reduction mastopexy.
The right, irradiated breast was a greater challenge because o the intrinsic dam-
age caused by the multiple previous surgeries, irradiation, and capsular contrac-
ture. Whereas one option would be to abandon implant reconstruction and proceed
with autologous reconstruction, we thought that the implant reconstruction in this
patient could be salvaged and signi cantly improved with judicious surgery. On
the right side, we recommended removal o the saline implant, per orming a cap-
sulectomy in conjunction with radial scoring o the lateral breast f ap to improve
the contour, and placement o a new silicone gel implant o appropriate volume.
She was in ormed o the possibility o autologous at gra ting to the lumpectomy
site, but i this was necessary, we recommended that it be per ormed as a delayed
procedure.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the right saline implant
Right capsulectomy and radial scoring to release constricted areas
Insertion o a new silicone gel implant on right side
Le t implant removal and replacement
Le t reduction mammaplasty

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
748
TECHNIQ UE
Preoperative measurements and skin markings were made with the patient in the
upright position. The proposed level to which the le t nipple needed to be elevated
to match the right nipple was marked on the breast meridian. The breast was man-
ually displaced, rst medially and then laterally, and a line was drawn rom the new
nipple position to the midpoint o the IMF, to mark the proposed vertical limbs o
the Wise pattern mastopexy. The length o the limbs was not delineated, but rather
le t to be determined intraoperatively, to match the dimensions o the right breast
a ter revision.
The surgical procedure was started on the right side, where the old periareolar
scar that was used to insert the saline implant was reincised. The wound was deep-
ened to the capsule, which was opened with electrocautery. The saline implant was
inadvertently punctured, the saline aspirated, and the def ated implant removed.
The implant was noted to be a 350 cc device; however, the actual ll volume was
unknown.
The capsule was uni ormly thickened and contracted; a circum erential capsu-
lotomy was per ormed around the base o the periprosthetic pocket, and the sub-
muscular pocket was enlarged superiorly and medially. Most o the capsule was
resected in the upper and medial portions o the breast. Both laterally in the area
o the previous lumpectomies and in eriorly where the tissues were thinner, we
scored the capsule radially to help release and expand the f aps. Beneath the NAC,
where the tissue was very thin, the capsule was le t in situ. Sizers were used to de-
termine the appropriate implant or reconstruction. A ter adequate hemostasis was
secured, the pocket was irrigated with double antibiotic solution (bacitracin and
neomycin), a 7 mm f at Jackson-Pratt drain placed, and a Mentor (Mentor Corp.,
Santa Barbara, CA) 475 cc moderate plus pro le smooth round gel implant in-
serted. The incisions were closed in layers.
Markings
for reduction
mastopexy
to elevate
the nipple
Capsule
excised
Radial
scoring
New IMF

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

749
On the le t side, with the breast skin under modest tension to simulate closure over
a new implant, the length o the vertical limbs was marked to match the distance
rom the IMF to the areola on the right side, which was 8 cm. The remainder o the
Wise skin pattern was then marked. A 4 cm circular template was used to delineate
the new areolar border. The incisions were made and superior and in erior vertical
pedicles created by deepithelializing the f ap both above and below the NAC. In e-
riorly, the width o the pedicle was maintained at 7 cm to ensure adequate blood
supply to the NAC. We excised a triangle o skin and breast tissue medially and lat-
erally, all the way down to and including the anterior capsule around the implant.
An intact saline implant was removed and noted to weigh 385 cc. A total capsulec-
tomy was per ormed, except along the undersur ace o the vertical dermal and pa-
renchymal pedicle, where the capsule was le t in situ to enhance circulation to the
NAC.
An inf atable sizer was placed in the pocket, the mastopexy incisions were tempo-
rarily closed with skin staples, and the patient was placed in the ull sitting position
on the operating table. The sizer was gradually inf ated to determine the volume
that would best match the right breast. The patient was re-placed in the supine po-
sition, the sizer def ated and removed, and a nal check made to ensure complete
hemostasis. The pocket was irrigated with antibiotic solution, a 7 mm f at Jackson-
Pratt drain placed, and a Mentor 300 cc moderate plus pro le smooth round gel
implant inserted. The incisions were closed in customary ashion.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient had an unevent ul postoperative course and has enjoyed a good result.
Postoperative photographs depict her appearance 11⁄2 years a ter the procedure.
Breast symmetry has been signi cantly improved. The NACs are at a similar level
on both sides. Capsular contracture on the right side has been eliminated, and this
patient continues to have a Baker grade I capsule at 18 months.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
750
The contour de ormity o the lateral aspect o the right breast has been improved,
although the depression has not been entirely eliminated. The constriction o the
lower pole o the right breast has been released so that the shape matches the le t
side much better. This patient is satis ed with her result. Additional minimally in-
vasive procedures could be undertaken to urther enhance the result, including at
gra ting to the residual contour irregularity o the lateral right breast and the appli-
cation o topical bleaching agents to reduce hyperpigmentation o the skin adjacent
to the old lumpectomy scar.

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

751
TEACHING PO INTS
This case illustrates some o the strategies that may be employed to improve the
dis gurement and asymmetry that sometimes results rom breast conservation
therapy. Caution must always be exercised when per orming reoperative surgery
on an irradiated breast. Radiation causes signi cant, irreversible damage to the
blood supply o all tissues within the path o the ionizing beam. To reduce the risk
o f ap ischemia and prevent delayed wound healing, the surgical approach on the
right side was through the old periareolar scar instead o the lumpectomy scar. An
aggressive capsulectomy was per ormed to try to reduce the risk o recurrent con-
tracture, but the capsulectomy was restricted to areas o the breast where the f aps
were thicker and less likely to have sustained signi cant radiation damage. In areas
at high risk, such as the lateral and in erior poles o the breast, radial capsulotomy
was per ormed. The capsule was spared in the thinnest area, the subareolar region,
which had a surgical scar immediately adjacent to it.
There are several reasons that we per ormed surgery on the right side be ore ini-
tiating surgery on the le t breast. First, the degree to which irradiated tissues will
stretch and con orm to an implant is always unpredictable; there ore the nal di-
mensions o the reconstructed right breast cannot be known until the skin clo-
sure has been completed. Second, when trying to match asymmetrical breasts, it
is a good general principle to complete the surgery on the more di cult side rst,
because there is more f exibility on the easier side or matching both volume and
shape. For example, in this patient, the vertical length o the mastopexy f aps on the
le t side was not determined until the nal dimensions on the right side had been
ascertained. Likewise, the implant volume and pro le used on the le t side was de-
cided only a ter the nal size and shape o the right breast were known.
Because o the unpredictability and increased risks associated with operating on ir-
radiated tissues, patients must be thoroughly educated about this be ore surgery. It
is important to emphasize the increased risks o f ap necrosis, wound dehiscence,
implant exposure, in ection, delayed wound healing, recurrent capsular contracture,
suboptimal aesthetic outcomes, and the need or additional procedures. Despite the
increased risks, signi cant improvement can be achieved in most patients with care-
ul preoperative planning and judiciously per ormed surgery.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
752
BIBLIO GRAPHY
Asgeirsson KS, Rasheed T, McCulley SJ, et al. Oncological and cosmetic outcomes o oncoplastic
breast conserving surgery. Eur J Surg Oncol 31:817-823, 2005.
Bajaj AK, Kon PS, Oberg KC, et al. Aesthetic outcomes in patients undergoing breast conservation
therapy or the treatment o localized breast cancer. Plast Reconstr Surg 114:1442-1449, 2004.
Clough KB, Cuminet J, Fitoussi A, et al. Cosmetic sequelae a ter conservative treatment or breast can-
cer: classi cation and results o surgical correction. Ann Plast Surg 41:471-481, 1998.
Fitoussi AD, Berry MG, Couturaud B, et al. Management o the post-breast-conserving therapy de ect:
extended ollow-up and reclassi cation. Plast Reconstr Surg 125:783-791, 2010.
Olivotto IA, Rose MA, Osteen R, et al. Late cosmetic outcome a ter conservative surgery and radio-
therapy: analysis o causes o cosmetic ailure. Int J Radiat Oncol Biol Phys 17:747-753, 1989.
Rigotti G, Marchi A, Galiè M, et al. Clinical treatment o radiotherapy tissue damage by lipoaspirate
transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg
119:1409-1422, 2007.

46c Correction of a Lumpectomy Defect
With a Latissimus Dorsi Flap and Implant
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
The patient requested a breast augmentation to increase her breast volume. She had
hoped that a simple augmentation would also improve the appearance o her right
breast, which had a de ormity rom a lumpectomy and radiation several years pre-
viously. She also complained o asymmetry: the right breast was slightly smaller a -
ter the lumpectomy and radiation. The right NAC location was also distorted rom
the previous treatment.
753

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
754
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On physical examination, it is apparent that the lumpectomy has created a so t
tissue de ect in the right breast, with the majority o the volume loss in the lateral
in erior quadrant o the breast. There is distortion o the IMF, which is pulling the
NAC laterally and in eriorly. The tissue around the lumpectomy is rm rom irradi-
ation, and the entire breast is somewhat immobile and rm. There is also hyperpig-
mentation along the right lateral IMF, and a transverse crease in the upper pole o
the irradiated right breast extends laterally and crosses the anterior axillary line.
ANALYSIS O F THE PRO BLEM
This patient demonstrates several problems associated with lumpectomy and ra-
diation treatment. Her de ormity is particularly pronounced because the lumpec-
tomy was close to the lateral IMF, which has distorted the lower pole o the breast.
Lumpectomies create greater distortion in volume and shape in patients with rela-
tively small breasts than in patients with larger volume breasts. Involvement o the
IMF o ten requires the trans er o autologous tissue in the orm o a muscle f ap to
not only restore volume but also correct old problems. The breast is also less com-
pliant a ter irradiation; there ore simply inserting an implant may not release the
contracted tissue adequately.
It was explained to the patient that new tissue with a healthy blood supply was
necessary and that either an implant or expander would also be required. Because
the patient was hoping or a single-stage procedure, an adjustable implant ex-
pander was more likely to correct both volume and shape.
RECOMMENDED SOLUTION TO THE PROBLEM
Excision o the contracted scar around the lumpectomy site
Use o a small latissimus dorsi f ap to release the contracted lateral in erior
breast mound with muscle and a skin island
Insertion o an adjustable saline implant subpectorally on the right side and a
subpectoral standard saline implant on the le t

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

755
TECHNIQ UE
There were several goals in this case. This was not a simple breast augmentation, as
the patient had hoped, because o the loss o volume, contracture, and general sti -
ness o the entire right breast.
The rst step in the operating room was excising the transverse irradiated scar o
the right breast and releasing the tissue in the surrounding area. In these cases, the
de ect is requently larger than expected a ter the contracture is released, and it is
important to wait until a ter the release be ore committing to the size o the latis-
simus dorsi skin island. Once the dimensions o the de ect were determined, the
patient was rotated onto her side, and an 8 by 4 cm skin island with underlying
muscle was elevated rom the right side o her back. This was passed through a
subcutaneous skin tunnel under the axilla into the surgical de ect. The latissimus
dorsi muscle was sutured to the pectoralis muscle above it so that there would be
total muscle coverage o the implant. It is important to design the skin island on the
myocutaneous f ap so that as it is rotated onto the anterior chest, the skin island is
in erior and the muscle extends superiorly. Very little muscle was needed in eriorly;
most muscle was needed superiorly to attach to the pectoralis muscle. This method
provided complete muscle coverage o the device, which is critical in irradiated pa-
tients.
An adjustable saline implant was inserted subpectorally, and the repair was closed
superiorly between the latissimus dorsi and pectoralis muscles. On the le t breast, a
standard saline implant was placed in the subpectoral position.
The lling valve on the right side was placed subcutaneously on the lateral chest
wall. This valve was used to serially ll the right device to match to the le t static
implant.
Skin flap
Latissimus
dorsi flap
Skin flap
Latissimus
dorsi flap

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
756
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
This result would not be achievable with just a standard augmentation. The breasts
now have volume symmetry in both rontal and lateral projection, and the supe-
rior ullness o the breasts is also symmetrical. The one downside to this solution is
the appearance o a patch o skin on the right lower lateral breast. In addition, the
nipple has remained slightly lateral and in erior as a result o general contracture
o the breast rom the radiation treatment. Overall, this is a good result in a patient
with this common problem that occurs a ter lumpectomy and radiation.

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

757
TEACHING PO INTS
It is very di cult to insert an implant in many patients a ter lumpectomy and ra-
diation to correct segmental de ormation. In this patient, simply placing an implant
in the right breast would have increased the volume but would not have corrected
the de ormity in the lateral lower pole o the breast. A ter irradiation, the entire
breast is usually a ected, with general sti ness and loss o tissue compliance. The
addition o autologous tissue replaces the so t tissue de ect and brings in new blood
supply. De ects along the IMF are especially di cult to correct; there ore this is
where a latissimus dorsi f ap is particularly use ul. Because the f ap is in a lateral
superior direction, it gives added support to the lower lateral portion o the breast.
A TRAM f ap also could have been used; however, a pedicled TRAM f ap tends to
pull the breast in eriorly and does not provide as much muscle volume as does a la-
tissimus dorsi f ap.
The bene t o an adjustable implant is that it takes several months be ore the -
nal volume o the right side can be determined because o swelling and progressive
latissimus muscle atrophy. As the volume changes, the adjustable implant can be
lled to maintain symmetry.
BIBLIO GRAPHY
El-Marakby HH, Kotb MH. Oncoplastic volume replacement with latissimus dorsi myocutaneous
f ap in patients with large ptotic breasts. Is it easible? J Egypt Natl Canc Inst 23:163-169, 2011.
Hernanz F, Sánchez S, Cerdeira MP, et al. Long-term results o breast conservation and immediate vol-
ume replacement with myocutaneous latissimus dorsi f ap. World J Surg Oncol 9:159, 2011.
Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal approach to breast reconstruction
a ter partial mastectomy. Plast Reconstr Surg 117:1-11; discussion 12-14, 2006.
Kronowitz SJ, Hunt KK, Kuerer HM, et al. Practical guidelines or repair o partial mastectomy de-
ects using the breast reduction technique in patients undergoing breast conservation therapy.
Plast Reconstr Surg 120:1755-1768, 2007.
Liu J, Fang ZY, Xiao CH, et al. [Application o latissimus dorsi muscle f ap or breast conservation in
breast cancer] Zhonghua Zhong Liu Za Zhi 33:305-307, 2011.
Navin C, Agrawal A, Kolar KM. The use o latissimus dorsi minif ap or reconstruction ollowing
breast-conserving surgery: experience o a small breast unit in a district hospital. World J Surg
31:46-50, 2007.
Zaha H, Onomura M. Breast conserving surgery using the round block technique combined with par-
tial reconstruction using the latissimus dorsi f ap. Breast 22:98-99, 2013.

46d Latissimus Dorsi Flap Reconstruction
and Contralateral Mastopexy
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
Approximately 1 year be ore presenting, this 51-year-old woman with T2 N0 inva-
sive ductal carcinoma o the in erior le t breast underwent neoadjuvant chemother-
apy and then a partial mastectomy and postoperative whole-breast radiotherapy o
50 Gy in 25 ractions plus a tumor bed boost o 10 Gy in 5 ractions. She had no
other signi cant medical or surgical history and was a nonsmoker. Her bra size was
a 38C. She sought the opinion o a plastic surgeon regarding the resulting de or-
mity o her le t breast a ter her cancer treatment.
758

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

759
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has signi cant volume de ciency o the in erior pole with overlying hy-
perpigmented, retracted, irradiated skin. A well-healed partial mastectomy scar is
located in erolaterally, and she has in erior displacement o her le t nipple because
o the contracture o the irradiated skin. The contralateral breast has grade 2 pto-
sis. The distance rom her sternal notch to her nipple was 27 cm on the right and
25.5 cm on the le t. Her IMF-to-nipple distance is 6.5 cm on the right and 3.5 cm
on le t.
ANALYSIS O F THE PRO BLEM
Signi cant breast asymmetry warranting correction may occur in up to 35% o
women receiving breast conservation therapy with partial mastectomy and adju-
vant radiotherapy, as is the case or this patient. She had a severe de ormity in the
in erior aspect o the le t breast with tethering o the NAC causing it to become
inverted in eriorly. Retraction rom the radiation created a paucity o skin and vol-
ume, and notable NAC malposition, compared with the right side. A pedicled latis-
simus dorsi f ap could replace both skin and volume, and help to buttress the NAC
back to its proper position.
In addition to the de ormity o the le t breast, this patient had Baker grade II ptosis
o the right breast. A mastopexy would improve symmetry.
RECOMMENDED SOLUTION TO THE PROBLEM
Pedicled ipsilateral latissimus dorsi myocutaneous f ap
Staged contralateral mastopexy

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
760
TECHNIQ UE
In the supine position, we re-created the le t breast de ect by releasing the tethered,
inelastic skin with excision and radial scoring. This patient was then turned to the
le t lateral decubitus position, and a pedicled ipsilateral latissimus dorsi myocutane-
ous f ap was harvested.
This patient was then returned to the supine position and the f ap was inset; this re-
stored skin and volume to the breast, and allowed the NAC to be repositioned ap-
propriately.
Six months postoperatively, the incisions had healed
well and a good cosmetic result had been achieved.
Residual asymmetry rom the ptosis on the right side
was then addressed using a concentric mastopexy
with a Benelli-type circumareolar suture.

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

761
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
At 3 months a ter having the mastopexy, which was 9 months a ter getting the
f ap, this patient has healed well and is satis ed with her result. The le t breast has
been restored to its original volume, and the nipple has been properly repositioned.
There is good symmetry. The scar rom the inset o the latissimus dorsi f ap is in ull
view anteriorly; however, it is easily concealable under clothing.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
762
TEACHING PO INTS
Un ortunately it is only a ter whole breast radiation therapy that patients who have
undergone a partial mastectomy most requently present to plastic surgeons or
aesthetic concerns. Repairing de ormities in these patients o tentimes requires local
f ap trans er, typically a latissimus dorsi or thoracodorsal artery per orator, because
local tissue rearrangement or breast reduction techniques are susceptible to high
complication rates when there is a history o whole breast irradiation. These more
extensive f ap procedures are not ideal, because the skin replacement that is o ten
necessary introduces conspicuous scars on the breast and juxtaposes discordant
sur ace textures and pigment shades. Choosing to use a local f ap in the setting o a
partial mastectomy de ect would also eliminate this reconstructive option in the u-
ture i a completion mastectomy must be per ormed because o recurrence. In cases
with signi cantly distorted breasts, it may even be pre erable to per orm a comple-
tion mastectomy with a total breast reconstruction rather than attempt a partial re-
pair, which would leave breast tissue that may be at risk o recurrent disease.
Probably the most important point is that whenever easible, oncoplastic repair
before whole breast irradiation is pre erable because it has the lowest complica-
tion rate and is simple because it uses the remaining breast tissue, which maintains
the color and texture match o the breast. Recruiting additional skin is rarely nec-
essary be ore irradiation. Only later, a ter the e ects o radiation have caused skin
contracture, may new skin be required, even though no skin was actually removed
during the partial mastectomy. In cases o signi cant volume resection with skin
preservation, a latissimus dorsi f ap with a deepithelialized skin paddle can be con-
sidered as an option or immediate reconstruction.
Management algorithms using immediate reparative techniques allow the plastic
surgeon to participate in the planning o the surgical approach to tumor resection
and may mitigate any need or subsequent breast reconstruction that would likely
be more complex in nature. Adhering to this approach should reduce the incidence
o a partial mastectomy leading to severe de ormities that develop a ter whole
breast radiation therapy.
It should be noted, however, with the increasing use o partial breast irradiation as
an alternative to whole breast irradiation, manipulation o the remaining breast tis-
sue or reconstruction may become a viable option, because this surrounding breast
tissue su ers less damage and remains more so t and pliable.

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

763
This is an example o a 56-year-old woman who presented with a similar de ormity
as described in the previous case, also 1 year a ter partial mastectomy. However,
this patient received partial breast irradiation using brachytherapy with a Mam-
moSite device 34 Gy over 5 days. In contrast to whole breast irradiation, the partial
breast irradiation used in this patient created an opportunity to use the remaining
breast tissue or the repair. Because the surrounding breast tissue had not been irra-
diated, a breast reduction technique using a superomedial dermoglandular pedicle
was now possible as a reconstructive option. Although this patient proceeded to de-
velop some localized contracture in the a ected le t breast, no wound healing prob-
lems developed.
BIBLIO GRAPHY
Bajaj AK, Kon PS, Oberg KC, Miles DA. Aesthetic outcomes in patients undergoing breast conserva-
tion therapy or the treatment o localized breast cancer. Plast Reconstr Surg 114:1442-1449,
2004.
Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management algorithm and practical oncoplastic
surgical techniques or repairing partial mastectomy de ects. Plast Reconstr Surg 122:1631-1647,
2008.

46e Combined Latissimus Dorsi Myocutaneous Flap
With Implants and Fat Transfer
a l ber t Lo sk en
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 44-year-old woman with a history o le t breast cancer underwent a lumpec-
tomy and radiotherapy 7 years ago. She presented with a de ormity resulting rom
breast-conserving therapy (BCT) and desired better symmetry and possibly a slight
increase in the volume o both breasts. She was otherwise healthy.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient has a Clough II BCT de ormity, which is de ned as an obvious de or-
mity associated with some asymmetry and some distortion o the NAC. She has a
scar in the upper outer quadrant o her le t breast, with some radiation brosis o
the mound and radiation changes to the skin envelope. The NAC is retracted su-
perolaterally. She has nipple asymmetry as well as mound asymmetry, with the le t
breast mound being smaller and higher. She has no ptosis on the le t.
ANALYSIS O F THE PRO BLEM
The goal in correcting BCT de ormities is to improve the overall shape and symme-
try. In this patient, the nipple position needs to be lower and more medial. This will
require replacement with skin and volume in the location o the de ect to restore
contour and essentially push the nipple in eriorly and medially. The le t breast is
smaller in volume, and the IMF is higher on that side.
764

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

765
RECOMMENDED SOLUTION TO THE PROBLEM
Reconstruction o the de ect
Use o a latissimus dorsi myocutaneous f ap or skin and volume
Insertion o implants to add volume, improve symmetry, and allow IMF adjust-
ment
Fat injections or contour
TECHNIQ UE
The patient was initially prepared in the supine position, and the lumpectomy de-
ect was opened. The de ect was essentially opened down to the chest wall, and all
tight scar tissue was released and resected where necessary. The humeral insertion
was identi ed and thoracodorsal vessels dissected.
She was then prepared again in the lateral decubitus position, and an elliptical skin
island and muscle-sparing latissimus dorsi f ap was harvested. Subscarpal at was
preserved or volume. The de ect was lled to correct the nipple position. A contra-
lateral augmentation was per ormed to increase the volume on the right side.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
766
This resulted in improved nipple position; however, the le t IMF was still higher
and the volume o the le t breast was less.
An implant was placed in the subglandular position on the le t side, which cor-
rected the volume asymmetry and lowered the IMF.
To improve contour, 25 cc at injections were then per ormed laterally.

Chapter 46 • Deformities After Lumpectomy, Radiation, and Breast Reconstruction

767
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The latissimus f ap repositioned the nipple and provided better contour to allow
placement o an implant. The augmentation was conservative; however, it did im-
prove the volume. The contour was corrected laterally with at injections. Im-
proved symmetry in shape, contour, and nipple position was achieved. The patient
is shown at 14 months postoperatively. She is likely to be at increased uture risk
or capsular contracture on the le t side because o the history o irradiation on that
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768
TEACHING PO INTS
The majority o BCT de ormities, especially in women with small breasts, require
some type o f ap reconstruction. Multiple procedures are o ten required to repair
complex de ects. Although the augmentation was requested by the patient, this ap-
proach allowed adjustment in the IMF position as well as correction o volume di -
erences. Implants are not typically indicated or the correction o a BCT de ormity,
but they can be help ul when used in conjunction with a f ap in a patient with a
contour irregularity.
There are many reconstructive tools available to correct a BCT de ormity. Correc-
tion can require many di erent procedures, depending on the anatomic steps that
must be taken. These procedures can be per ormed simultaneously, yet it is o ten
sa er to separate the variables and correct various aspects at di erent stages. The
patient would accept additional procedures i they would result in better symmetry.
BIBLIO GRAPHY
Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques allow extensive resections or breast-
conserving therapy o breast carcinomas. Ann Surg 237:26-34, 2003.
Fitoussi AD, Berry MG, Couturaud B, et al. Management o the post-breast-conserving therapy de ect:
extended ollow-up and reclassi cation. Plast Reconstr Surg 125:783-791, 2010.
Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management algorithm and practical oncoplastic
surgical techniques or repairing partial mastectomy de ects. Plast Reconstr Surg 122:1631-1647,
2008.
Losken A, Hamdi M. Partial breast reconstruction: current perspectives. Plast Reconstr Surg 124:722-
736, 2009.

46f Repair With a Latissimus Dorsi Flap
and an Adjustable Implant
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
The patient presented 14 years a ter undergoing immediate breast reconstruction
with an expander and implant.
At the patient’s 2-year ollow-up, we noticed that she was starting to develop a con-
tracture with slight elevation o the reconstructed le t breast mound. The process
o contracture and elevation o the implant continued; when the patient was seen
14 years postoperatively, she had both severe contracture and signi cant elevation
o the reconstructed IMF. During this time, she had undergone multiple mastopex-
ies o her right breast in an unsuccess ul attempt to maintain symmetry.
2 years after reconstruction
with expander and implant
6 years after reconstruction
Preoperative
769

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
770
Fourteen years a ter reconstruction, the patient was seen in our clinic; she com-
plained o di culty wearing clothing because o the signi cant asymmetry. Also,
her le t breast had become f at with a lack o projection, and she needed to wear
padding in her clothing. She was a healthy 62-year-old with no other abnormalities
or de ormities o the chest wall.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has signi cant elevation o the le t IMF, compression o the implant be-
neath the muscle, and elevation o the NAC. On her right side, she has progressive
ptosis. She has gained some weight over the 14-year interval since her original sur-
gery, and the ptosis has progressed despite her having multiple previous mastopex-
ies. The patient desires a single surgical procedure i it is easible.
ANALYSIS O F THE PRO BLEM
Un ortunately, recurrent capsular contracture and implant distortion are not un-
common among expander-implant reconstructive patients. Analysis o the problem
requires an assessment o the amount o skin and so t tissue in the contracted area.
In some patients, there is such a small amount o tissue remaining that an autolo-
gous tissue trans er is required. Attempts at reexpansion in these patients can be
rustrating, and there is a high ailure rate.
RECOMMENDED SOLUTION TO THE PROBLEM
An autologous tissue trans er to create breast symmetry
(This was necessary because o the loss o the entire lower hal o the patient’s
reconstructed breast mound)
Re-creation o the entire length o the IMF by using a latissimus dorsi myocuta-
neous f ap with a relatively large skin island
Placement o an adjustable saline expander-implant (Spectrum, Mentor Corp,
Irving, TX)
(Because this patient wanted a single operation, and because the latissimus dorsi
f ap would not create adequate volume by itsel , and a tissue expander is there-
ore necessary in such cases)
Regulation o contour postoperatively, and maintenance o symmetry with the
right side by placing an adjustable implant on the le t side