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

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
772
TEACHING PO INTS
In patients with severe contracture a ter implant reconstruction, autologous tissue
trans er is requently necessary. I the loss o tissue is in the lower pole o the recon-
structed mound, the best option is to set the f ap along a new IMF. Adjustable im-
plants can be a good alternative in the attempt to achieve symmetry.
BIBLIO GRAPHY
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.

46g Revision of TRAM Flap Breast Reconstruction
Den n is C. h a mmo n d
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This morbidly obese 42-year-old woman had previously undergone a lumpectomy
and radiation or invasive ductal cancer o the right breast. Obtaining adequate re-
section margins required two separate lumpectomies that resulted in a signi cant
so t tissue de ect in the medial aspect o the right breast. This patient’s preoperative
weight reached as high as 350 pounds. A ter completion o radiotherapy, she suc-
cess ully underwent gastric bypass surgery be ore presenting or de nitive bilateral
mastectomy because o her continuing concerns about tumor recurrence. At that
time she underwent an immediate rst-stage bilateral latissimus dorsi myocutane-
ous f ap breast reconstruction along with the placement o tissue expanders.
An immediate reconstruction o the le t NAC was per ormed. Over the next year,
this patient steadily lost weight, ultimately reaching a stable weight o 190 pounds.
Preoperative marks were made in preparation or bilateral skin-sparing mastectomy
with immediate latissimus dorsi f ap and tissue expander breast reconstruction.
773

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
774
The patient is shown 1 year a ter expander placement. She had lost approximately
80 pounds rom gastric bypass surgery, as shown by the marks in preparation or
the bilateral expander replacement with a permanent implant. At that time second-
stage reconstruction was per ormed, exchanging the tissue expanders or perma-
nent 550 cc moderate pro le plus smooth round silicone gel implants and recon-
structing the right NAC. She subsequently developed a Baker grade IV capsular
contracture in the right breast that was treated with capsulectomy.
This patient is shown 8 months a ter capsulectomy on the right with recurrent con-
tracture, so t tissue thinning o the lower pole, and impending exposure o the im-
plant. Preoperative marks were made in preparation or right bipedicle TRAM f ap
breast reconstruction, and the planned excision o lower pole skin in preparation
or TRAM f ap insetting.

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

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She is shown a ter debridement o the lower pole skin. The NAC and the rem-
nant o the previous latissimus f ap are le t in situ to contribute to the volume and
shape o the reconstructed breast. She is shown a ter insetting o the TRAM f ap
skin island. Recurrent contracture in the right breast with severe thinning o the
skin envelope in the in erior pole, along with impending exposure o the implant,
prompted a major revision with conversion to an autologous-based reconstruction
using a double pedicle TRAM f ap breast reconstruction. Although the TRAM f ap
survived completely, this patient has presented with an additional de ormity in the
right reconstructed breast and is seeking additional revision.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
This patient is shown 8 months a ter insetting o the TRAM f ap. There is asymme-
try in the location o the IMF, the position o the NAC, and the shape and volume
o the reconstructed breasts. She also has loss o the right IMF, asymmetry in the
volume o the breasts and the position o the reconstructed NACs, and an irregu-
larly shaped and redundant TRAM f ap skin island. The breast is otherwise so t
without any evidence o at necrosis. The le t breast is so t and otherwise without
complication.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
776
ANALYSIS O F THE PRO BLEM
In the process o insetting the TRAM f ap, an excessively large TRAM f ap skin is-
land was inset into the de ect present in the lower pole o the right breast. In addi-
tion, during debridement o the compromised skin and management o the previous
capsule, the IMF was excessively lowered, creating an asymmetric breast ootprint
when compared with the le t breast. As the swelling associated with the procedure
resolved, the entire right breast and NAC dri ted even lower, creating a signi cant
asymmetry when compared with the le t side.
RECOMMENDED SOLUTION TO THE PROBLEM
Per orm a second-stage TRAM f ap revision to the right breast to provide the
desired symmetry
Artistic reduction o the skin envelope o the TRAM f ap so that the lower pole
o the right breast is smoothly and accurately reconstructed to match the le t
side
Simultaneous reduction o the volume o the right breast to match the size o
the le t breast
Suture plication o the IMF higher up under the breast to provide a stable oun-
dation to the breast and to create a old that is symmetrical with the opposite
side to allow the patient to wear a support garment com ortably a ter surgery
Incorporation o a small mastopexy cutout in the skin resection pattern supe-
rior to the NAC to provide a li t to the NAC position, and preoperative marks in
preparation or second-stage TRAM f ap revision
TECHNIQ UE
The procedure was per ormed on an outpatient basis with this patient under gen-
eral anesthesia. The rst maneuver was the repositioning o the IMF to provide a
stable oundation to the breast.

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

777
Next the volume was adjusted using standard liposuction to care ully remove the
desired amount o volume. Finally, the skin envelope was plicated around the entire
periphery o the TRAM f ap skin inland using the “hammock e ect” o the f ap to
shape the lower pole. Incorporating a small mastopexy cutout into the skin resec-
tion pattern accomplished the desired li t o the NAC position. The photo shows
her immediate appearance a ter revision o the right reconstructed breast.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The nal result is shown 3 years a ter the original TRAM f ap was per ormed. The
reconstructed NACs have been tattooed. Despite the two di erent methods o re-
construction, reasonable symmetry between the two breasts has been obtained. Im-
portant anatomic landmarks including the IMF, breast volume and shape, and the
position o the NAC are quite symmetric, leading to an overall aesthetic reconstruc-
tive result.

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
778
TEACHING PO INTS
Despite a long reconstructive process, the nal result shows an excellent aesthetic
result, particularly when considering the act that multiple complications have been
overcome. Most o these complications can be traced back to the original preop-
erative condition when radiation to the right breast compromised these tissues and
led to the original and most signi cant complications o capsular contracture. In
addition, this case highlights the challenges presented by a “delayed” breast recon-
struction, in which a TRAM f ap is inset into a de ect using not only the volume
o the f ap but also the skin island o the TRAM to shape the breast together. Ad-
justing the TRAM skin island to the proper dimensions is an artistic challenge that
very o ten requires a secondary revision to get it “just right.” However, when all o
these elements are managed appropriately, outstanding aesthetic results can still be
achieved.
BIBLIO GRAPHY
Atisha DM, Alderman AK, Kuhn LE, et al. The impact o obesity on patient satis action with breast
reconstruction. Plast Reconstr Surg 121:1893-1899, 2008.
Dolmans GH, van de Kar AL, van Rappard JH, et al. Nipple reconstruction: the “Hammond” f ap.
Plast Reconstr Surg 121:353-354, 2008.
Hammond DC, Khuthaila D, Kim J. The skate f ap purse-string technique or nipple-areola complex
reconstruction. Plast Reconstr Surg 120:399-406, 2007.
Hammond DC, Simon AM, Khuthaila DK, et al. Latissimus dorsi f ap salvage o the partially ailed
TRAM f ap breast reconstruction. Plast Reconstr Surg 120:382-389, 2007.
Levine SM, Patel N, Disa JJ. Outcomes o delayed abdominal-based autologous reconstruction versus
latissimus dorsi f ap plus implant reconstruction in previously irradiated patients. Ann Plast Surg
69:380-382, 2012.

46h Completion of Previous Lumpectomy
and Radiation With Nipple-Sparing Mastectomy
and a Buried TRAM Flap
Ja c k Fish er
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 49-year-old patient had undergone a bilateral breast augmentation with sub-
glandular implants 8 years previously. Two years a ter the original augmentation,
she developed cancer in her right breast and was treated with lumpectomy and ra-
diotherapy. The original breast implant had been le t in place. She then developed
recurrent capsules with Baker grade IV rmness and underwent multiple capsu-
lectomies unsuccess ully. At the time she was seen, she had already had three open
capsulectomies and complained o a tight, hard breast with pain and discom ort.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
On physical examination, the right breast is rm and displaced superiorly. Her right
IMF is elevated, and the breast is essentially xed to the chest wall. The right NAC
is in a airly good position, and she has airly good symmetry although her right
breast is slightly smaller compared with her le t breast.
779

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
780
The patient has had previous pregnancies and has adequate lower abdominal at
or use with potential breast reconstruction.
ANALYSIS O F THE PRO BLEM
It is common or patients with implants in place to have signi cant problems with
capsular contracture a ter radiotherapy. I the implant is in the subglandular space,
severe capsular contracture is almost guaranteed a ter radiation treatment with
lumpectomy. The act that the patient had recurrent capsular contracture a ter
three open capsulectomies demonstrates that surgery cannot solve the underlying
biologic problem in this patient. The only solution is replacement with healthy vas-
cularized tissue to replace the tissue that was damaged by the radiation treatments.
Because this patient has remaining breast tissue that is at risk or recurring cancer,
an important option to consider is a completion mastectomy at the time o breast
reconstruction.
RECOMMENDED SOLUTION TO THE PROBLEM
Per orming a nipple-sparing mastectomy through an in ramammary incision
Simultaneous use o a unilateral deepithelialized TRAM f ap with a small skin
island to reconstruct the breast
Repositioning o the contracted IMF as a result o the radiation treatment
At the time o the nipple-sparing mastectomy, transmit tissue cores rom the
subareolar area or study to assess or any disease requiring removal o the NAC
(results were negative)

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

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TECHNIQ UE
An in ramammary incision was made along the length o the contracted right
breast. Using sharp dissection, the overlying skin f ap was separated rom the un-
derlying breast tissue. The rm, irradiated breast mound was then dissected o
the underlying musculature and removed through the in ramammary incision. The
breast specimen was appropriately marked or pathologic evaluation. A TRAM f ap
with a vertical skin island along the medial portion o the f ap was raised in a uni-
lateral ashion. Except or the small ellipse o skin, the entire f ap was deepithelial-
ized while it was still sitting on the abdominal wall. A muscle-sparing pedicle was
elevated and the f ap was inset, with the skin island re-creating the previously con-
stricted IMF.
Removal of
irradiated breast
Deepithelialized
tissue buried
to create
breast fullness
TRAM flap skin
island creates
lower pole of
new IMF

Part V-C: Deformities Associated With Lumpectomy, Partial Mastectomies, and Radiation
782
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS

The patient obtained an excellent re-
sult with both adequate volume and
contour. The skin island allowed the
lower pole o the breast to relax, and
it also created a new IMF. The patient
is shown preoperatively, 8 months
a ter surgery, and again 3 years a ter
surgery. At 8 months a ter surgery, the
patient maintained a so t breast with
good contour, and she continued to
have an excellent result at 3 years a -
ter surgery.

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

783
TEACHING PO INTS
Irradiated subcutaneous implants almost always develop severe capsular contrac-
ture. In this case this is veri ed by the act that the patient had three unsuccess ul
open capsulectomies. The skin envelope a ter radiotherapy is usually retracted; re-
quently, a small skin island is required to reestablish the original sur ace area. Be-
cause irradiated tissue remaining in the breast is at risk, it was appropriate to do a
completion mastectomy be ore f ap reconstruction.
BIBLIO GRAPHY
Alperovich M, Tanna N, Samra F, et al. Nipple-sparing mastectomy in patients with a history o re-
duction mammaplasty or mastopexy: how sa e is it? Plast Reconstr Surg 131:962-967, 2013.
Endara M, Chen D, Verma K, Nahabedian MY, Spear SL. Breast reconstruction ollowing nipple-
sparing mastectomy: a systematic review o the literature with pooled analysis. Plast Reconstr
Surg 132:1043-1054, 2013.
Gahm J, Hansson P, Brandberg Y, Wickman M. Breast sensibility a ter bilateral risk-reducing mas-
tectomy and immediate breast reconstruction: a prospective study. J Plast Reconstr Aesthet Surg
66:1521-1527, 2013.
Kim HJ, Park EH, Lim WS, et al. Nipple areola skin-sparing mastectomy with immediate transverse
rectus abdominis musculocutaneous f ap reconstruction is an oncologically sa e procedure: a
single center study. Ann Surg 251:493-498, 2010.
Vaughn CJ, Peled AW, Esserman LJ, Foster RD. Feasibility o per orming total skin-sparing mastec-
tomy in patients with prior circumareolar mastopexy or reduction mammoplasty incisions. Ann
Plast Surg. 2013 Jun 19. [Epub ahead o print]

(Trang không có chữ)

Pa r t V-D
Cancer Recurrence
After Breast
Reconstruction

Carcinoma o the breast is the most commonly occurring malignancy among women in the
United States. It is estimated that an American woman has a one in eight li etime risk o de-
veloping breast cancer. Recent decades have witnessed tremendous advances in the diagnosis
and treatment o breast cancer, and the growing popularity o breast conservation therapy has
resulted in many women being spared the de ormity o mastectomy. However, substantial
numbers o patients continue to require mastectomy, and plastic surgeons have developed re-
markable techniques to restore a normal-appearing, natural- eeling breast. It has been repeat-
edly demonstrated that breast reconstruction does not increase the risk o cancer recurrence;
however, a certain percentage o reconstructed breast cancer patients inevitably will develop
recurrent disease. Among the actors that increase the risk o local recurrence are positive lymph
nodes, larger tumor size, close tumor margins, and younger age at the time o cancer diagnosis.
Most recurrences in reconstructed women are in the skin or subcutaneous tissue, with the re-
mainder occurring in the chest wall. Typically, local recurrence is e ectively managed with sur-
gical excision o the involved tissues, chemotherapy, and/or radiation therapy; however, treat-
ment o recurrent tumor a ter reconstruction o ten detracts rom the aesthetic result and may
create additional de ormity requiring urther reconstructive e orts. The di f culty in success ully
rehabilitating patients who experience recurrence a ter reconstruction is o ten compounded by
the need or radiation and chemotherapy. Despite these challenges, advances in reconstructive
techniques have given plastic surgeons and their patients many new salvage options. The ol-
lowing cases are examples o techniques that may be adapted to restore satis actory unction
and appearance in women who experience local recurrence a ter implant or autologous breast
reconstruction.

Chapter 47 Cancer Recurrence After Implant Reconstruction
47a Salvage With Latissimus Dorsi Myocutaneous Flap Reconstruction and Tissue Expander
Placement
47b Latissimus Dorsi Flap With Implant Salvage
Chapter 48 Cancer Recurrence After Autologous Reconstruction
48a Revision With DIEP Flap Advancement
787

(Trang không có chữ)

47a Salvage With Latissimus Dorsi Myocutaneous Flap
Reconstruction and Tissue Expander Placement
Al ber t Lo sk en
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 66-year-old woman with a history o bilateral invasive ductal carcinoma had
undergone a bilateral skin-sparing mastectomy and expander-to-implant recon-
struction 20 years earlier. She presented with a palpable mass beneath the skin me-
dially on her right side and was diagnosed with recurrent ductal carcinoma. The
plan was to per orm a right wide reexcision and axillary node dissection. The pa-
tient had a strong smoking history.
c h APt e r 4 7
CANCER RECURRENCE AFTER
IMPLANT RECONSTRUCTION
789

Part V-D: Cancer Recurrence After Breast Reconstruction
790
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a bilateral implant reconstruction. She has acceptable symme-
try with slightly more ptosis on her le t side and loss o projection o both recon-
structed nipples. Bruising is present on her right breast medially, and both implants
are so t. Wide excision and nodal biopsy were per ormed. The largest dimension o
her malignant oci was 3 cm, with a close margin posteriorly. The posterior margin
was essentially the capsule, which was removed with the excision.
ANALYSIS O F THE PRO BLEM
The de ect was ull thickness and medial to her NAC. A wide ellipse o skin was
excised, and skin aps were elevated superiorly and in eriorly. Remaining breast tis-
sue and the tumor were resected o the capsule. A portion o the capsule beneath
the tumor was removed, along with the old silicone implant. The de ect thus con-
sisted o mastectomy skin aps and a partial submuscular pocket with capsule.
RECOMMENDED SOLUTION TO THE PROBLEM
Latissimus dorsi myocutaneous ap reconstruction
Placement o an expander
Contralateral revision at a later stage
TECHNIQ UE
The patient was placed in a lateral decubitus position. An elliptical skin island was
incised over the latissimus dorsi muscle. Dissection was continued down to Scarpa’s
ascia. The entire muscle with sub-Scarpa ascial at and the skin island was ele-
vated to the level o the axilla. A subcutaneous tunnel to the breast pocket was cre-
ated, and the ap was passed through it. Once the patient was supine, the humeral
insertion was taken down and a ormal capsulotomy was per ormed. An anatomi-
cally shaped tissue expander was then placed in the submuscular pocket at the level
o the IMF and in ated with 350 cc o saline solution. The latissimus muscle was
sutured circum erentially to the chest wall and to the residual pectoralis muscle and
capsule. The latissimus skin island was then cut to the appropriate size and sutured
to the remaining mastectomy skin aps.

Chapter 47 • Cancer Recurrence After Implant Reconstruction

791
The patient had an acceptable result a ter bilateral implant reconstruction. The
plan or treatment o the superf cial recurrence was to remove a su f cient amount
o skin and re-create the mastectomy aps. Because the patient had a strong smok-
ing history, a latissimus myocutaneous ap was planned not only to provide skin
replacement, but also to ensure additional vascularity and bulk beneath potentially
compromised skin aps. The other reason or choosing a latissimus ap was be-
cause the patient needed postoperative radiotherapy. A avorable result was not
likely a ter simple wide excision and placement o a tissue expander alone. This
ap creates a more durable environment that tolerates radiation better than an ex-
pander alone.
No standardized protocol exists or screening a reconstructed breast. Physi-
cal examination is o ten adequate to identi y local recurrence; mammography,
ultrasound, and ultrasound-guided f ne-needle aspiration are e ective adjuncts
or the detection o recurrent breast cancer a ter autologous and implant-based
reconstructions.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown a ter radiotherapy. She had moderate radiation-induced
changes o her skin. However, the expander pocket was relatively so t, and she had
an acceptable shape. Her le t breast was less natural appearing.

Part V-D: Cancer Recurrence After Breast Reconstruction
792
Six months a ter the completion o radiotherapy, she was taken to the OR and her
le t implant was replaced with a smaller, 350 cc moderate prof le plus gel implant.
Her IMF was redef ned. Her right tissue expander was exchanged or a 250 cc
moderate prof le gel implant. Because o the limitations in the irradiated skin en-
velope on her right, a smaller implant size was chosen or both sides to provide a
more natural result. The f nal procedure was a le t nipple reconstruction in the mi-
nor room and a nipple-areolar tattoo.
One year a ter radiotherapy, her breasts were so t with good symmetry. She had
very minimal capsular contracture on the right. The position o her IMF and the
lower pole shape were similar on both sides. She has no evidence o recurrent dis-
ease at her 3-year ollow-up.

Chapter 47 • Cancer Recurrence After Implant Reconstruction

793
TEACHING PO INTS
Local recurrence o cancer a ter mastectomy and reconstruction is generally consid-
ered a poor prognostic indicator. Immediate breast reconstruction using either au-
tologous tissue or implants has not been ound to impair the ability to detect local
recurrence. Recurrence o approximately 2% was reported in a large series. As in
this patient, most tumors recurred in the skin and subcutaneous tissue (72% ), and
only about 28% were on the chest wall. Patients whose recurrence was in the skin
or subcutaneous layers had a reduced incidence o metastatic disease and higher
overall survival. Breast reconstruction has not been shown to impair the ability to
detect recurrence, because most o ten it is superf cial. The importance o clinical
examination and appropriate surveillance cannot be overemphasized. Most recur-
rences will occur in the f rst 2 years a ter mastectomy and reconstruction. In a re-
cent study o 495 breast reconstructions in patients with T1/T2 tumors and zero
to three positive lymph nodes, who did not have radiotherapy, the recurrence rate
was 3.2% at 71⁄2 years. Independent variables associated with increased risk o re-
currence were age younger than 40 years, estrogen receptor–negative patient status,
and T2 tumors. With multimodal therapy, and radiotherapy reserved to treat recur-
rence, the overall 10-year survival was similar in patients with local recurrence and
those without local recurrence (87.5% versus 90.3% , respectively). Despite tumor
recurrence and the need or radiotherapy, breast reconstruction can be o ered to
these patients and provide avorable aesthetic results.
BIBLIO GRAPHY
Eidelman Y, Liebling RW, Buchbinder S, et al. Mammography in the evaluation o masses in breasts
reconstructed with TRAM aps. Ann Plast Surg 41:229-233, 1998.
Edeiken BS, Fornage BD, Bedi DG, et al. Recurrence in autogenous myocutaneous ap reconstruction
a ter mastectomy or primary breast cancer: US diagnosis. Radiology 227:542-548, 2003.
Langstein HN, Cheng MH, Singletary SE, et al. Breast cancer recurrence a ter immediate reconstruc-
tion: patterns and signif cance. Plast Reconstr Surg 111:712-722, 2003.
Sharma R, Rourke LL, Kronowitz SJ, et al. Management o local-regional recurrence ollowing imme-
diate breast reconstruction in patients with early breast cancer treated without postmastectomy
radiation therapy. Plast Reconstr Surg 127:1763-1772, 2011.

47b Latissimus Dorsi Flap With Implant Salvage
Gl y n Jo n es
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 58-year-old woman with carcinoma o the le t breast had a modif ed radical
mastectomy 7 years previously, ollowed by radiotherapy. Two years later she had
breast reconstruction with a tissue expander and subsequent implant placement.
Despite radiotherapy, she had a relatively so t and symmetrical result. One month
be ore her annual ollow-up visit, a nodule developed in the upper portion o her
le t breast. Fine-needle aspiration revealed metastatic carcinoma. Excision o the
area o recurrence with a satis actory margin o clearance was planned.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a airly symmetrical chest wall be ore tumor recurrence. The mas-
tectomy ap had originally been closed using external retention sutures, which le t
extremely unsightly cross-hatching across the upper pole o the breast. The adjacent
tissues are airly so t despite radiation therapy, but there is no tissue redundancy to
allow or any orm o primary closure. The thin, radiated pectoralis major muscle
is adherent to the mastectomy skin, but animation de ormity is not prominent. The
le t breast is more ptotic than the right, and the latissimus donor site is available
and airly generous.
Area of local
recurrence
794

Chapter 47 • Cancer Recurrence After Implant Reconstruction

795
ANALYSIS O F THE PRO BLEM
A ull-thickness de ect involving the pectoralis major muscle and extending rom
the 10 o’clock to the 1 o’clock position will be required to achieve clear margins.
The shape and symmetry o the patient’s breasts are otherwise pleasing. The patient
underwent radiotherapy to her le t breast.
RECOMMENDED SOLUTION TO THE PROBLEM
Radial resection o the recurrence to achieve wide margins o clearance
Elevation o a latissimus dorsi myocutaneous ap with an oblique skin island
Flap transposition to the anterior chest with implant salvage
TECHNIQ UE
A latissimus dorsi ap was planned to replace the patient’s missing skin. The ap
was pedicled on the thoracodorsal vessel rom the back and was placed into the de-
ect. No evidence o systemic disease was noted, but a course o chemotherapy was
scheduled. Because she had undergone radiotherapy a ter the initial mastectomy, no
additional radiotherapy was indicated.

Part V-D: Cancer Recurrence After Breast Reconstruction
796
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient has recovered unevent ully and healed well. Her original breast shape
has been preserved in the long term despite the inevitable muscle atrophy that oc-
curs with latissimus aps, and she maintains a grade I capsule. She has no rippling.
The skin island has replaced the cutaneous component o the resection, and muscle
and vascularized at on the extended autologous latissimus harvest have replaced
the tissue def cit incurred by a deep tumorectomy. Typically, the latissimus skin is-
land is relatively hyperpigmented compared to breast skin. A slightly more yellow-
ish color is apparent with the latissimus skin island in this patient, yet the overall
color match is airly good. Overall breast shape and symmetry have been preserved,
and the patient is able to com ortably wear a bra. She has survived or 3 years a ter
her surgery and continues to do well.
TEACHING PO INTS
Local breast cancer recurrence requently is within close proximity to the primary
tumor on the overlying skin aps covering a reconstruction. I this occurs a ter im-
plant reconstruction, exposure o the device is a potential problem o wide reexci-
sion. The latissimus dorsi myocutaneous ap provides a valuable method o recon-
structing and salvaging these de ects.
Correction o major chest wall de ormity should aim to replace all o the missing
elements with appropriate tissues: in this case, breast skin is replaced with healthy
unradiated back skin and subcutaneous tissue, and pectoral muscle is replaced with
latissimus muscle and posterior back at. Resection o recurrences should be ag-
gressive, with generous aps used or reconstruction. Initial reconstructive e orts
should aim to overcorrect the de ect to compensate or inevitable latissimus ap
shrinkage. Flaps should be anchored accurately to f t the de ect ully, without al-
lowing or the development o hollow areas or at spots: i it does not look good
on the operating table, it certainly will not improve postoperatively.

Chapter 47 • Cancer Recurrence After Implant Reconstruction

797
BIBLIO GRAPHY
Agaoglu G, Erol OO. Delayed breast reconstruction with latissimus dorsi ap. Aesthetic Plast Surg
33:413-420, 2009.
Anscher MW, Jones P, Prosnitz LR, et al. Local ailure and margin status in early-stage breast carci-
noma treated with conservation surgery and radiation therapy. Ann Surg 218:22-28, 1993.
Cagli B, Segreto F, Persichetti P. Implant breast reconstruction a ter salvage mastectomy in irradiated
patients. Ann Plast Surg 67:565, 2011.
Chang DW, Barnea Y, Robb GL. E ects o an autologous ap combined with an implant or breast re-
construction: an evaluation o 1000 consecutive reconstructions o previously irradiated breasts.
Plast Reconstr Surg 122:356-362, 2008.
Classen J, Nitzsche S, Wallwiener D, et al. Fibrotic changes a ter postmastectomy radiotherapy and re-
constructive surgery in breast cancer. A retrospective analysis in 109 patients. Strahlenther Onkol
186:630-636, 2010.
Dejode M, Bordes V, Ja ré I, et al. [Oncologic, unctional, and aesthetics results; evaluation o the
quality o li e a ter latissimus dorsi ap breast reconstruction. About a retrospective series o 450
patients] Ann Chir Plast Esthet 56:207-215, 2011.
Garusi C, Lohsiriwat V, Brenelli F, et al. The value o latissimus dorsi ap with implant reconstruc-
tion or total mastectomy a ter conservative breast cancer surgery recurrence. Breast 20:141-144,
2011.
Kääriäinen M, Kuokkanen H. The signif cance o latissimus dorsi ap innervation in delayed breast
reconstruction: a prospective randomized study-magnetic resonance imaging and histologic f nd-
ings. Plast Reconstr Surg 130:189e; author reply 189e–190e, 2012.
Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review o the litera-
ture. Plast Reconstr Surg 124:395-408, 2009.
Lindegren A, Halle M, Docherty Skogh AC, Edsander-Nord A. Postmastectomy breast reconstruction
in the irradiated breast: a comparative study o DIEP and latissimus dorsi ap outcome. Plast Re-
constr Surg 130:10-18, 2012.
McCarthy CM, Pusic AL, Scla ani L, et al. Breast cancer recurrence ollowing prosthetic, postmastec-
tomy reconstruction: incidence, detection, and treatment. Plast Reconstr Surg 121:381-388, 2008.
Persichetti P, Cagli B, Simone P, et al. Implant breast reconstruction a ter salvage mastectomy in previ-
ously irradiated patients. Ann Plast Surg 62:350-354, 2009.
Salmon RJ, Razaboni R, Soussaline M. The use o the latissimus dorsi musculocutaneous ap ollow-
ing recurrence o cancer in irradiated breasts. Br J Plast Surg 41:41-44, 1988.
Schaverien MV, Stutchf eld BM, Raine C, Dixon JM. Implant-based augmentation mammaplasty ol-
lowing breast conservation surgery. Ann Plast Surg 69:240-243, 2012.
Tomita K, Yano K, Nishibayashi A, et al. The role o latissimus dorsi myocutaneous aps in secondary
breast reconstruction a ter breast-conserving surgery. Eplasty 13:e28, 2013.

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C h a p t e r 4 8
CANCER RECURRENCE AFTER
AUTOLOGOUS RECONSTRUCTION
48a Revision With DIEP Flap Advancement
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
At age 41 this patient was diagnosed with le t breast T3 N1 M0 invasive ductal
carcinoma or which she underwent excision and reconstruction with a delayed
deep in erior epigastric per orator (DIEP) ap ollowing adjuvant radiotherapy. She
did well postoperatively, was satisf ed with her result, and did not require any ur-
ther surgery. Eight years a ter her initial diagnosis, she developed a 2 by 1 by 2 cm
le t parasternal subcutaneous nodule that was ound to be a high-grade sarcoma,
likely secondary to the radiotherapy. She would require radical resection o the
mass and as well as mobilization and revision o the ree ap.
799

Part V-D: Cancer Recurrence After Breast Reconstruction
800
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
ANALYSIS O F THE PRO BLEM
The de ect was large enough to require so t tissue to f ll the void, since primary
closure would place the wound edges under too much tension and not adequately
ablate the dead space. Transposition o a rectus ap would provide an alternative
solution; however, mobilization o the DIEP ap would preserve the rectus muscle
should it be needed in the uture or urther reconstruction.
RECOMMENDED SOLUTION TO THE PROBLEM
Identif cation o a vascular pedicle
Medial mobilization o the DIEP ap
TECHNIQ UE
Skin incisions were made along the previous inset scars o the ap. Low-volume
tumescent solution was then gently injected subcutaneously to help develop the
dissection plane through which the ap would be mobilized. Sharp dissection then
released the overlying skin rom the ap. The vascular pedicle was identif ed and
ound to be patent.
A ter excision o the specimen, a de ect approxi-
mately 5 cm in diameter was present along the me-
dial aspect o the ap, exposing the sternum at its
base.

Chapter 48 • Cancer Recurrence After Autologous Reconstruction

801
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
TEACHING PO INTS
Treatment options a ter a local recurrence vary, depending on the location and pa-
thology. For a recurrence a ter autologous reconstruction has been per ormed, on-
cologic issues (such as invasion o the pedicle) or aesthetic concerns usually do not
necessitate removal o the ap. I the ap is preserved and is to be mobilized, it is
imperative to identi y the vascular pedicle f rst. Once this is done, the ap can be
repositioned sa ely. Use o the internal mammary vessels as anastomotic recipients
may allow a greater degree o reedom or mobilizing the ap on the chest wall.
The benef t o mobilization is to allow all dead space rom the resection o recur-
rent cancer to be obliterated. Otherwise, wound-healing problems and resultant de-
ormities may occur, especially i adjuvant radiotherapy becomes necessary.
BIBLIO GRAPHY
Howard MA, Polo K, Pusic AL, et al. Breast cancer local recurrence a ter mastectomy and TRAM ap
reconstruction: incidence and treatment options. Plast Reconstr Surg 117:1381-1386, 2006.
Patterson SG, Teller P, Iyengar R, et al. Locoregional recurrence a ter mastectomy with immedi-
ate transverse rectus abdominis myocutaneous (TRAM) ap reconstruction. Ann Surg Oncol
19:2679-2684, 2012.
The ap was then dissected ree rom its chest wall
attachments, leaving the ap completely mobilized
on its vascular pedicle. This allowed signif cant mo-
bilization, and the ap could be sa ely repositioned
medially so that it adequately f lled the de ect.
At 2 weeks postoperatively the patient was healing
well, although signif cant asymmetry remained, or
which she will likely undergo a contralateral pro-
cedure and liposculpting to improve the synmastia.
Fortunately, adjuvant radiotherapy was not indicated
or the patient.

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Pa r t VI
Problems Associated
With the Nipple-Areola
Complex

In many respects, the nipple-areola complex (NAC) is the de ning element o the emale breast.
It is o ten observed ollowing reconstruction that even the most aesthetically pleasing, realistic-
appearing breast mound does not look like a breast until a ter the NAC has been abricated.
Likewise, in the aesthetic patient, distortion, depigmentation, or loss o the nipple is a devastat-
ing postoperative complication. Dis gurement or partial loss o the nipple is rare a ter primary
augmentation. However, as the complexity o breast surgery increases, so too does the risk o
poor outcomes with regard to the nipple and areola. Thus, patients having mastopexy, com-
bined augmentation and mastopexy, or breast reduction are at progressively increased risk or
nipple-areola complications. There is a wide spectrum o untoward outcomes that may occur,
ranging rom unsatis actory areolar size or shape, poor scarring, nipple de ormity, or malposi-
tion, to total necrosis o the NAC. Typically, the most severe complications result rom dimin-
ished circulation to the nipple and areola, which occurs most o ten rom compromised venous
drainage (congestion) but sometimes rom insu cient arterial inf ow (ischemia). Nipple conges-
tion and/or ischemia can result in pigmentation changes, loss o nipple projection, in ection,
wound separation and, in the worst cases, partial or even total loss o the nipple and areola.
Fortunately, there are many surgical strategies and techniques available to restore an aestheti-
cally pleasing NAC in patients who have experienced unsatis actory cosmetic results a ter prior
breast surgery. In this section, the contributors share some examples o the myriad approaches
available either to reduce damage to the nipple when it is threatened, or to restore the appear-
ance o the nipple and areola in situations in which patients have sustained tissue damage or
loss as a result o previous surgery.

Se c t Io n
Chapter 49 Malposition, Asymmetry, Loss of Projection, Overprojection,
and Areolar Spreading
49a Combined Expander-Implant Exchange With Capsulorrhaphies and Fat Gra ting
49b Repeat Free Nipple Gra t With Periareolar Mastopexy
49c Reciprocal Transposition Flaps
49d Wraparound Flap to Restore Nipple Projection
Complications and Suboptimal Aesthetic Outcomes
805

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49a Combined Expander-Implant Exchange
With Capsulorrhaphies and Fat Grafting
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 37-year-old woman with a BRCA mutation underwent bilateral risk-reducing,
nipple-sparing mastectomies through lateral incisions. Immediate subpectoral tissue
expanders with acellular dermal matrix were placed. Seven months later expansion
was completed, and an implant exchange was planned.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has developed breast asymmetry, including a laterally displaced NAC
on her le t. The le t breast is also slightly less ptotic. In addition, superior pole ull-
ness is lacking bilaterally.
c h a Pt e r 4 9
MALPOSITION, ASYMMETRY,
LOSS OF PROJECTION,
OVERPROJECTION,
AND AREOLAR SPREADING
807

Part VI: Problems Associated With the Nipple-Areola Complex
808
ANALYSIS O F THE PRO BLEM
NAC asymmetry o ten occurs a ter bilateral nipple-sparing mastectomy reconstruc-
tion with expanders and implants. For this reason, some authors advocate a two-
stage approach. This provides an opportunity to treat asymmetry and contour de-
ormity, which are anticipated at the time o implant exchange. NAC repositioning
needs to be considered or this patient, along with bilateral volume enhancement
superiorly to augment the upper pole and provide an overall uller shape.
RECOMMENDED SOLUTION TO THE PROBLEM
Removal o the expanders
Placement o implants
Capsulorrhaphies and capsulotomies to medialize the right implant and lateral-
ize the le t implant
Autologous at gra ting to the upper poles
TECHNIQ UE
The previous lateral mastectomy incisions were opened, and the expanders were
removed. Extensive capsule work was required on the le t side, including a cap-
sulorrhaphy in the in eromedial aspect o the breast, because the implant was too
medially positioned and the position o the NAC was thus malpositioned too ar
laterally. On the right side, capsulotomies were made in the medial aspect o the
capsule to allow the implant volume to better ll out this area. Multiple capsuloto-
mies were per ormed to allow lateral repositioning o the implant. A ter completion
o the capsule work, the implants were placed into the pockets and the incisions
were closed. Autologous at was gra ted to the superior poles bilaterally.
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
Capsulotomies, capsulorrhaphies, and autologous at gra ting have helped to pro-
vide an overall better aesthetic outcome to the reconstruction. Symmetry and ptosis

Chapter 49 • Malposition, Asymmetry, Loss of Projection, Overprojection, and Areolar Spreading

809
are improved. Lateral displacement o her le t NAC persists, likely rom ailure to
e ectively lateralize the implant.
TEACHING PO INTS
Nipple malposition a ter nipple-sparing mastectomy is a very di cult problem to
correct. However, the general results o nipple-sparing mastectomy reconstruction
are usually satis actory and the patient is very satis ed, as in this case. It is critical
to prevent lateral NAC displacement. This can be achieved by not overextending
the dissection too ar medially at the time o pectoralis elevation during the initial
operation. The expander or implant must be per ectly centered beneath the NAC. I
it is placed too ar medially, the resultant breast mound will displace the NAC later-
ally. A laterally oriented access incision helps to prevent this problem. Unlike a ra-
dial or periareolar incision, a lateral incision can place less tethering orces on the
NAC, thus preventing postoperative retraction.
Acellular dermal matrix can be used as an internal sling to hold the expander or
implant in place and take all pressure o the mastectomy f aps. This allows the skin
envelope to be independent o the underlying device and acilitates appropriate
skin redraping, with a properly centered NAC. Acellular dermal matrix may also
be used at a second stage to help shape the capsule and position the NAC. Whether
reconstruction is per ormed in one or two stages, the position o the prosthesis will
have a major impact on the location o the NAC. Capsulotomies and capsulorrha-
phies at later stages are rarely completely e ective, as in this case.
The use o skin releases to correct malposition o ten is ine ective and potentially
destructive. Although mobilization o the NAC using crescentic, periareolar skin
excisions seems to be an intuitive approach to the problem, it requires very serious
consideration. I the skin f aps are thin and tight, this technique can cause an open
wound with a potentially exposed implant beneath. Furthermore, per usion to the
NAC can become compromised by the introduction o additional skin incisions. A
much less e ective option is to per orm ree nipple gra ts, which rarely take prop-
erly, leading to very unsatis actory aesthetic results.
BIBLIO GRAPHY
Taneda H, Sakai S. Transposition technique or correction o a malpositioned nipple-areola com-
plex a ter reconstruction ollowing a nipple-sparing mastectomy: a case report. Ann Plast Surg
67:579-582, 2011.

49b Repeat Free Nipple Graft With Periareolar
Mastopexy
a l ber t Lo sk en
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 44-year-old woman had a prior breast reduction and subsequently devel-
oped le t breast cancer. She underwent a le t skin-sparing mastectomy and TRAM
f ap breast reconstruction. Three months a ter reconstruction she wanted smaller
breasts. She had a small reduction on her right side and a le t reduction revision o
her reconstructed breast.
At that time her le t nipple was reconstructed with a ree nipple gra t. An areolar
tattoo was per ormed later.
810

Chapter 49 • Malposition, Asymmetry, Loss of Projection, Overprojection, and Areolar Spreading

811
She then presented because her le t NAC and breast contour were not aesthetically
appealing.
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
The patient has a reconstructed le t nipple with an areolar tattoo, which has the ap-
pearance o a circle within the larger circle rom her skin-sparing mastectomy pat-
tern. Her nipple has good projection, but is smaller than the right nipple. The lower
pole o her breast mound has a contour irregularity.
ANALYSIS O F THE PRO BLEM
The circle (NAC) within a circle phenomenon distracted rom the overall aesthetic
appearance o the patient’s breast mound. Although the original periareolar mastec-
tomy scar will likely ade with time, skin color and texture were di erent enough
that they will never be as natural appearing as i the skin island were the same size
as the opposite NAC. The best way to achieve a normal-appearing breast a ter skin-
sparing mastectomy with autologous reconstruction is to make the skin island the
same size as the opposite NAC. The irregularity in contour in the lower pole was
undesirable and a ected the overall aesthetics signi cantly. The problems there-
ore were the size o the skin island, poor nipple projection, and a lower pole breast
contour de ect.
RECOMMENDED SOLUTION TO THE PROBLEM
Skin island reduction in a periareolar mastopexy ashion
Repeat a ree nipple gra t
Scar revision o the lower pole

Part VI: Problems Associated With the Nipple-Areola Complex
812
TECHNIQ UE
The patient was marked preoperatively, and the size o her right NAC was mea-
sured. This was then drawn as a circle on her le t breast within the TRAM f ap skin
island. The two concentric circles were incised and the skin between them removed.
The mastectomy skin f aps were undermined circum erentially.
The outer, larger circle was then sutured in purse-string ashion to the smaller skin
island, reducing the diameter o the circle. At a later stage, nipple projection was
augmented with another ree composite nipple gra t. The previous nipple recon-
struction was then elevated in eriorly. A ree nipple gra t rom the contralateral side
was harvested and placed beneath the reconstructed nipple to augment the size. The
vertical scar was reincised, and the lower pole was revised to improve contour.
NAC
measurements
transferred to left
breast
Flap was
undermined
and lifted
Skin removed
between circles
Purse-string
suture

Chapter 49 • Malposition, Asymmetry, Loss of Projection, Overprojection, and Areolar Spreading

813
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown a month a ter her ree nipple gra t revision. When the skin is-
land is the same size as the opposite nipple, the reconstruction can be tattooed and
hidden within the NAC. This provides the most natural appearance possible. Al-
though this is an early result, nipple projection has been improved and matches the
opposite side. Lower pole contour is likewise improved.

Part VI: Problems Associated With the Nipple-Areola Complex
814
TEACHING PO INTS
The skin island should be the same size as the opposite NAC at the time o the orig-
inal reconstruction. Free nipple gra ting typically does not result in loss o projec-
tion. Revision was needed in this case, because the gra t was too small initially. Re-
peat ree nipple gra t is always an option, provided that donor nipple is adequate.
Placement o the new gra t in eriorly will hide the scar and likely improve results.
The purse-string nipple reconstruction technique can also be applied initially and is
thought to improve nipple projection, elevate the areola, and enhance cosmesis.
A local f ap such as a C-V f ap was an option in this patient either at the time o the
initial nipple reconstruction or secondarily. I a local f ap is planned, it is acceptable
to make it slightly bigger. Free nipple gra t, however, is bene cial in that it will also
reduce the size o the opposite nipple, improving overall symmetry. Loss o projec-
tion can result a ter local f ap procedures. Patients will generally tolerate additional
procedures i they will improve the overall cosmetic result.
BIBLIO GRAPHY
Hammond DC, Khuthaila D, Kim J. The skate f ap purse-string technique or nipple-areola complex
reconstruction. Plast Reconstr Surg 120:399-406, 2007.
Losken A, Carlson GW, Schoemann MB, et al. Factors that inf uence the completion o breast recon-
struction. Ann Plast Surg 52:258-261, 2004.
Otterburn D, Sikora KE, Losken A. An outcome evaluation ollowing postmastectomy nipple recon-
struction using the C-V f ap technique. Ann Plast Surg 64:574-578, 2010.
Wein eld AB, Somia N, Codner MA. Purse-string nipple reconstruction. Ann Plast Surg 61:364-367,
2008.

49c Reciprocal Transposition Flaps
Sc o t t L. Spea r , Fr a n k P. a l bin o
PATIENT HISTO RY LEADING TO THE SPECIFIC BREAST PRO BLEM
This 57-year-old woman had a history o biopsy-proven right breast ductal carci-
noma in situ (DCIS) ound on a routine mammogram. She was treated with a par-
tial mastectomy in combination with radiotherapy and recovered without incident.
Evaluation o the breast specimen taken at this time was negative or invasive can-
cer or margin involvement. She was then disease ree or 10 years. A palpable lump
prompted a right breast diagnostic mammogram and core needle biopsy signi cant
or estrogen-receptor negative, progesterone-receptor negative, and HER2 negative
invasive ductal carcinoma. She underwent neoadjuvant chemotherapy ollowed by
a right nipple-sparing mastectomy and immediate reconstruction with a tissue ex-
pander and AlloDerm (Li eCell, Branchburg, NJ). At a second stage, the expander
was exchanged with a Style 15 smooth round silicone 371 cc implant (Allergan,
Irvine, CA), and a mastopexy was per ormed on her contralateral breast. Postoper-
atively she had right superolateral nipple displacement. The patient did not have a
history o tobacco use, her BMI was 23.3, and she had a history o hypertension.
815

Part VI: Problems Associated With the Nipple-Areola Complex
816
ANATOMIC DESCRIPTIO N O F THE PATIENT’S CURRENT STATUS
Immediately a ter a nipple-sparing mastectomy and implant-based reconstruction,
the patient has a superiorly and laterally displaced right NAC. Her sternal notch-
to-nipple distance is short, whereas her nipple-to-IMF distance is too long (greater
than 8 cm). To measure nipple position relative to the entire vertical breast height,
horizontal lines (solid lines) can be drawn along the superior and in erior breast
boundaries. The vertical distance rom the top o the breast to the nipple (dashed
line) can then be measured and compared with the vertical height o the entire
breast to determine a ratio and the degree o nipple displacement. Nipples that are
positioned higher than the 45th percentile o the breast’s vertical height are de-
scribed as high riding. Based on a recently proposed classi cation system, nipples
that are between the 35th and 45th percentiles are classi ed as grade 1 (mild), those
between the 25th and 34th percentiles are grade 2 (moderate), and those less than
the 25th percentile are grade 3 (severe). This patient has a moderate nipple dis-
placement, with her nipple positioned at the 32nd percentile o the entire breast
vertical height. In addition to superior nipple displacement, she has a right lateral
breast contour de ormity along the incision line that is characterized by a central
tethering o the skin f aps to the chest wall. She also has a so t tissue de cit along
her upper breast border and complains o excess at in her right axilla.
ANALYSIS O F THE PRO BLEM
A high-riding NAC can occur a ter reconstructive or aesthetic breast surgery. Some
o the more common antecedent procedures that lead to a malpositioned NAC in-
clude mastopexy, reduction mammaplasty, augmentation, and mastectomy. Each o
these procedures a ects the nipple position either directly through movement o the

Chapter 49 • Malposition, Asymmetry, Loss of Projection, Overprojection, and Areolar Spreading

817
NAC into a new position (mastopexy and reduction mammaplasty) or indirectly
through change o the relative position o the nipple on the breast mound (aug-
mentation and nipple-sparing mastectomy). Nipple-sparing mastectomy procedures
seem particularly prone to the development o nipple malposition, because the orig-
inal position o the nipple is retained. The nal relationship between the nipple and
overall breast mound is less predictable. The retained NAC tends to move superi-
orly as a result o a mastectomy and reconstruction.
This patient developed a high-riding NAC a ter a nipple-sparing mastectomy and
exchange o the tissue expander with an implant. With the removal o breast paren-
chyma, the nipple and mastectomy skin tend to contract superiorly relative to the
underlying device. Although this patient was previously irradiated a ter a lumpec-
tomy, postmastectomy radiation also can contract mastectomy skin f aps superiorly,
urther elevating the NAC.
The management o a high-riding NAC is complicated because o the desire to pre-
vent scars above the nipple (in the superior aspect o the breast) and the limited
amount o skin between the nipple and sternal notch. Several strategies have been
developed to prevent these problems, including elevation o the height o the IMF
and the breast parenchyma, expansion o the skin superior to the NAC, and gra t-
ing o the NAC at a more appropriate location. A number o plastic surgeons have
described various f aps that transpose the NAC, o ten combined with a second f ap
that is either advanced or rotated to ll the resultant de ect. These reports have
demonstrated successes in patients with high-riding NACs rom a variety o cos-
metic and reconstructive causes. For this patient, the decision was made to pursue a
reciprocal transposition f ap because o the speci c cause o her nipple malposition
and its clinical presentation.
Two basic approaches are described or correction o nipple displacement. Both
rely on knowledge o whether the nipple, breast mound, or both contribute to the
problem. The patient had a long nipple-to-IMF distance but a relatively reasonable
position o her reconstructed breast. Consequently, the decision was made to cor-
rect her nipple malposition directly using reciprocal transposition f aps. Alterna-
tively, a reciprocal skin gra t was a reasonable solution.
RECOMMENDED SOLUTION TO THE PROBLEM
Reciprocal transposition f ap
Placement o a shaped implant
Liposuction o the right axilla
Lipo lling o the le t breast superior pole

Part VI: Problems Associated With the Nipple-Areola Complex
818
TECHNIQ UE
Preoperatively the patient’s current areolar position was marked. The adjacent,
desired areolar position was drawn as a circle that intersected the current areolar
border to ensure maximal blood supply o the NAC-carrying f ap. In the operat-
ing room, local anesthetic was in ltrated along the planned incision line. The f aps
were sharply cut with a scalpel blade, and the dissection was made super cial to
the breast capsule; minimal cautery was used to preserve the blood supply to the
transposition f aps. Because the patient had an underlying implant, the dissection
was super cial to the capsule or muscle ascia in the deep subcutaneous plane.
The minimal amount o undermining needed to allow f ap transposition was then
per ormed. Once the f aps were raised and transposed, they were sutured in place
with a ew buried dermal absorbable mono lament sutures, ollowed by running
or interrupted permanent mono lament skin sutures. All standing dog-ears were
le t in place to prevent compromise to f ap per usion. The f aps were covered with
antibiotic ointment and gauze. In a second stage, a shaped implant was placed.
Liposuction o her right axilla and lipo lling o her le t breast superior pole were
per ormed.

Chapter 49 • Malposition, Asymmetry, Loss of Projection, Overprojection, and Areolar Spreading

819
PO STO PERATIVE PHOTO GRAPHS AND CRITICAL EVALUATIO N
O F RESULTS
The patient is shown preoperatively (left), and 2 months a ter her reciprocal trans-
position f aps and 2 days a ter a subsequent touch-up revision (right) that consisted
o implant exchange to a shaped device and at gra ting to her superior breast pole.
The relationship between the NAC and breast mound is greatly improved. This ap-
proach proved success ul in this case.
TEACHING PO INTS
The cause o nipple malposition needs to be evaluated critically to develop a suc-
cess ul reconstructive plan. To correct the relative nipple position on the breast
mound, tissue expansion, mastopexy, or augmentation can be used to lower a post-
operative nipple indirectly. When reciprocal transposition f aps are per ormed, it is
critical to raise the f aps immediately above the capsule in the deep subcutaneous
plane. A reciprocal skin gra t may be employed to in eriorly rotate the nipple in the
setting o adequate skin quality and excellent tissue per usion. Prior radiotherapy
negatively a ects these actors and makes a skin gra t reconstruction less avorable.
This patient had a moderately high-riding nipple a ter a nipple-sparing mastectomy
and immediate two-stage prosthetic reconstruction in a previously irradiated eld.
I presented with a similar patient in the uture, we would likely repeat a reciprocal
transposition f ap. On the other hand, the availability o this technique is limited by
the anatomic location o the displaced nipple relative to the desired nipple position,
and by the location o preexisting scars on the breast. When the angle o transposi-
tion becomes too acute, concerns about tissue per usion can limit this option. Other
possible solutions include removal o the NAC altogether, leaving it as it is, or re-
positioning o the NAC as a ull-thickness skin gra t. Despite the drawbacks, limi-
tations, and risks o the reciprocal transposition technique, it may be the best o a
range o nonideal options.

Part VI: Problems Associated With the Nipple-Areola Complex
820
BIBLIO GRAPHY
Colwell AS, May JW Jr, Slavin SA. Lowering the postoperative high-riding nipple. Plast Reconstr Surg
120:596-599, 2007.
Frenkiel BA, Paci co MD, Morris R, et al. A solution to the high-riding nipple-areola complex. Aes-
thetic Plast Surg 34:525-527, 2010.
Mallucci P, Bran ord OA. Concepts in aesthetic breast dimensions: analysis o the ideal breast. J Plast
Reconstr Aesthet Surg 65:8-16, 2012.
Spear SL, Albino FA, Al-Attar A. Repairing the high-riding nipple with reciprocal transposition f aps.
Plast Reconstr Surg 131:687-689, 2013.
Spear SL, Ho man S. Relocation o the displaced nipple-areola by reciprocal skin gra ts. Plast Recon-
str Surg 101:1355-1358, 1998.